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THE 


PATHOLOGY  OF  THE  TEETH. 


THE 


PATHOLOGY  OF  THE  TEETH 


WITH  SPECIAL  REFERENCE  TO  THEIR 


ANATOMY  AND  PHYSIOLOGY. 


CARL  WEDL,  M.D., 

PROFESSOR     OF     HISTOLOGY     I X     THE     UNIVERSITY    OF     VIENNA,    ETC. 

TBANSLATED   FR03I   THE   GERMAN 

BY 

W.  E.  BOARDMAN,  M.D. 

With  Notes 

BY 

T.    B.    HITCHCOCK,    M.D.,    D.M.D., 

PROFESSOR  OF  DENTAL  PATHOLOGY  AND   THERAPEUTICS  IN  HARA'ARD  UNIVERSITY,   ETC. 


With  One  Hundred  and  Five  Illustrations. 


PHILADELPHIA: 

LINDSAY    &    BLAKISTOX. 

18  72. 


3  //5S'0O£66  55^6. 

Entered  according  to  Act  of  Congress,  in  the  year  1872, 

By  LINDSAY  &  BLAKISTON, 

In  the  OtEce  of  the  Librarian  of  Congress,  at  Washington,  D.  C. 


SIIBRMAIV  ci-  CO.,  PRiyXERS. 


100 


TRANSLATOR'S  PREFACE. 


Prof.  Wedl  is  widely  known  as  a  very  expert  and  thoroiigli  inves- 
tigator and  a  distinguished  scholar.  His  ''Kudiments  of  Pathological 
Histology,"  published  by  the  Sydenham  Society  in  1855,  will  justify 
the  assumption  that  anything  from  his  pen  will  prove  valuable. 

A  definite  idea  of  the  object  and  scope  of  the  present  work  rany  lie 
obtained  from  the  author's  preface  and  table  of  contents.  From  these 
it  will  be  seen  that  the  work  covers  the  whole  ground  of  the  Anatomy, 
Physiology,  and  Pathology  of  the  teeth  and  their  adnexa.  As  far  as 
was  practicable,  the  researches  of  others  were  made  use  of,  and,  in  ad-, 
dition,  there  will  be  found  much  that  is  entirely  original.  Indeed,  the 
work  forms  the  most  complete  treatise  of  its  kind  that  has  appeai'ed  in 
any  language.  When  we  consider  the  vast  amount  of  labor  required 
in  the  original  investigations  of  the  author,  in  the  collection  of  material 
and  the  reviewal  of  the  very  extensive  and  exceedingly  scattered  litera- 
ture of  the  subjects  of  which  he  treats,  it  must  be  acknowledged  that 
he  is  deserving  of  great  credit.  It  is  believed  that  the  work  will  prove 
a  valuable  one  for  the  dental  profession  in  this  country,  since  the  recent 
advances  which  have  been  made  here  in  the  requirements  of  the  students 
of  dental  science  necessitate  a  complete  work  for  the  purpose  of  a  guide 
in  future  original  investigations  as  well  as  of  studying  the  results  of 
the  researches  which  have  already  been  made.  General  practitioners, 
also,  of  medicine  and  surgery,  and  students  of  histology  will  fiud  in  it 
much  of  interest  and  value. 

I  have  endeavored  to  make  the  translation  as  literal  as  jiossible  and, 
at  the  same  time,  to  avoid  German  idioms ;  this  has  been  a  difficult 
task  on  account  of  the  peculiarities  in  the  author's  style  of  writing  as 
well  as  of  the  difficult  nature  of  the  subjects  of  which  he  .treats.    I  have 


VI  TRANSLATOR  S    PREFACE. 

Ijcen  unable  to  obtain,  for  the  purpose  of  comparison,  several  works 
and  journals  to  which  he  refers  and  from  which  he  quotes.  I  have 
thought  it  best  to  retain  everything  and  to  add  but  little.  It  Avas  sug- 
gested that  explanatory  notes  should  be  introduced  in  reference  to 
many  points  with  which  students  of  dental  science  alone  might  be  un- 
acquainted, but  it  was  found  that  too  much  space  would  be  required  in 
order  to  make  these  complete.  Many  of  the  works  to  which  reference 
is  made  in  the  text  are  readily  accessible,  and  from  them  the  reader 
can  obtain  more  satisfixctory  information  and  at  greater  length,  than 
could  be  included  within  the  limits  of  ordinary  notes. 

T  am  well  aware  that  the  critical  reader  will  find  many  blemishes  in 
the  translation  and  inelegant  diction,  which  I  trust  will  be  pardoned. 
Perhaps  I  have  not  correctly  appreciated  the  author's  meaning  in  some 
instances ;  errors  of  this  description  I  hope  the  critic  will  clearly  prove. 

Prof.  Plitchcock  has  carefully  reviewed  the  translation,  and  the  few- 
ness of  the  notes  which  he  has  found  necessary  to  add  will  indicate  the 
clearness  and  completeness  of  the  author's  treatment  of  the  subjects. 
I  am  greatly  indebted  to  Prof.  Hitchcock  for  the  assistance  which  I 
have  derived  from  conversations  with  him  and  from  his  library  and 
pathological  collection. 

Before  the  appearance  of  the  present  work,  Prof.  Wedl  published  an 
"Atlas  to  the  Pathology  of  the  Teeth,"  which  contains  one  hundred 
and  forty-tive  beautiful  engravings  in  illustration  of  malformations  and 
diseases  of  the  teeth,  together  with  explanations  of  the  same,  both  in 
German  and  English.  Although  this  Atlas  is  not  absolutely  essential 
to  the  understanding  of  the  present  work,  still,  as  I  have  found,  the 
full  appreciation  of  the  latter  will  be  facilitated  by  the  perusal  of  the 
former,  especially  of  those  portions  to  which  reference  is  made  in  the 
text. 

The  illustrations,  with  which  the  book  is  enriched,  are  from  electro- 
types, the  same  as  used  in  the  original  German  edition.  The  author's 
index  has  been  enlarged  considerably  ;  though  still  incomplete,  it  will, 
I  believe,  commend  itself  to  the  readers  as  a  valuable  addition. 

Prof.  "VVedl,  reserving  the  right  of  translation,  sent  a  copy  of  the 
original  edition  to  his  friend  and  former  pupil.  Dr.  Prancis  II.  Brown 
of  this  city,  Avith  the  request  that  he  would  translate  and  publish  the 
same.  He  concluded,  however,  that  his  numerous  duties  would  neces- 
sitate too  great  a  delay,  and  so  he  honored  me  with  the  request  to  as- 


TRANSLATOR  S    PREFACE.  Vll 

sunie  the  duty.  I  must  here  express  my  sincere  thanks  to  hhn  for  his 
undiminished  interest  in  the  progress  and  success  of  the  work,  and  for 
mucli  valuable  assistance.  To  many  others,  also,  whom  it  is  my 
privilege  to  consider  my  friends,  I  take  this  opportunity  of  renewing 
my  thanks  for  their  uniform  kindness,  their  willing  and  valuable  aid 
in  many  ways. 

in  closing",  I  will  express  the  hope  that  the  present  work  will  con- 
tribute to  the  advancement  of  the  study  of  dental  science  in  this  country, 
and  that  its  readers  will  derive  at  least  as  much  information  and  pleasure 
from  its  perusal  as  I  have  received  in  the  more  laboriovis  work  of  its 
translation. 

W.  E.  BOAEDMAN,  M.D. 

BosTox,  Mass.,  Sopternbor,  1872. 


AUTHOR'S  PREFACE. 


The  collection  of  the  vast  amount  of  material  requisite  for  a  work 
upon  a  special  branch  of  pathology  is  attended  with  manifold  difficulties. 
Our  efforts  are  the  sport  of  capricious  fortune  and  must  be  continued 
unremittingly  during  many  3ears  before  a  foundation  can  be  laid. 
Carabelli  made  collections  dviring  about  twenty,  and  Heider  during 
twenty-three  years,  and  they  succeeded  in  obtaining  valuable  series  of 
specimens  illustrating  the  anomalies  of  teeth.  The  latter  collection, 
however,  was  by  far  too  limited  for  the  requirements  of  a  special  study  ; 
indeed,  this  furnished  onlj"^  thirty -four  illustrations  for  the  "Atlas  to 
the  Pathology  of  the  Teeth,"  not  one-fourth  of  the  entire  number. 
Heider  and  I,  therefore,  were  compelled  to  devise  some  method  for 
obtainiug,  in  the  first  place,  the  necessary  material  for  our  work.  At 
our  request,  we  were  very  kindly  furnished  with  thousands  of  extracted 
teeth  from  the  Hospital  of  the  Charity  Friars  in  Vienna.  The  teeth 
alone,  however,  are  insufficient  for  our  purpose,  as  is  self-evident ;  it  is 
necessar}'  to  observe  them  in  situ,  in  the  cadaver  and  the  skeleton,  in 
order  to  study  the  connection  of  the  phenomena  in  succession.  In  com- 
mon with  those  of  experience,  I  can  recommend  such  a  collection  of 
diseased  teeth  as  a  fertile  source  of  instruction  to  the  practical  dentist. 

By  the  kindness  of  my  esteemed  friend.  Dr.  Ph.  Steinberger,  Yice- 
President  of  the  Austrian  Dental  Society,  I  have  had  the  opportunity, 
not  only  of  examining  Heider's  collection  together  with  the  children's 
skulls  which  were  collected  by  the  dentist  Terzer,  and  of  making  use 
of  a  number  of  plaster  casts,  but  I  have  also  had  at  my  disposal  the 
dental  libraiy  and  journals.  I  am  indebted  to  numerous  colleagues, 
whose  names  are  introduced  in  connection  with  the  proper  illustrations, 
for  very  important  additions  to  the  materials  at  my  disposal. 


X  author's  preface. 

After  the  death  of  Ileicler,  his  wife,  Marie  Heider,  allowed  me  to 
peruse  his  manuscripts  upon  subjects  connected  with  dentistry.  These 
comprised  outlines  of  lectures  upon  dentistry,  which  I  availed  myself 
of,  a  minute  description  of  the  exterior  of  the  teeth,  which  I  have  fol- 
lowed, almost  word  for  word,  and  a  synopsis  of  abnormal  sets  and 
anomalies  of  teeth,  which  I  have  rearranged  under  different  heads  with 
additions,  illustrations  and  special  explanations.  Finally,  before  his 
death,  Heider  furnished  me  with  written  communications  concerning 
his  clinical  observations  with  reference  to  caries  and  inflammation  of 
the  root-membrane,  which  I  have  introduced  under  his  name. 

The  papers  published  by  Heider  and  myself  in  common  and,  likewise, 
by  myself  alone,  in  the  "Deutsche  Vierteljahresschrift  fur  Zahnheil- 
kunde,"  I  have  introduced  in  the  text  either  unchanged  or  with  addi- 
tions, or  rewritten. 

Special  reference  has  been  made  to  the  ancient  and  modern  literature, 
so  far  as  space  and  the  means  at  my  disposal  would  allow,  and  in  this 
connection  I  have  derived  much  assistance  from  the  analects  of  A.  zur 
Nedden,  in  the  "  Deutsche  Yiertelj.  f.  Zahnh."  Unfortunately,  I  was 
unable  to  avail  myself  of  several  valuable  monographs  which  were  not 
to  be  obtained  through  the  booksellers. 

After  mvich  reflection  upon  the  subject,  I  decided  to  divide  the 
morbid  processes  into  seven  groups  or  families,  and  to  consider  the  dis- 
eases of  the  different  organs  in  connection  with  each  group.  In  this 
way,  I  think,  the  subjects  have  been  treated  in  a  more  connected  man- 
ner. The  anatomico-physiological  basis  has  been  adhered  to  strictly 
throughout  the  book  and,  when  it  has  appeared  advantageous,  com- 
parative pathologico-anatomical  data  have  been  introduced  in  order  to 
elucidate  the  processes.  "Whenever  the  needs  of  the  dentist  seemed  to 
require  it,  clinical  observations  have  been  combined  with  the  patho- 
logico-anatomical and,  in  this  way,  more  life  has  been  infused  into 
the  latter. 

In  such  a  recent  doctrine  as  the  pathology  of  the  teeth,  it  is  absolutely 
necessary  to  dwell  upon  isolated  observations  which  cannot  be  con- 
firmed until  a  later  period. 

The  pathological  is  preceded  by  an  anatomico-physiological  part 
which,  I  think,  contains  several  new  points,  the  results  of  my  own 
observations. 

For  the  more  minute  literature  of  this  portion  of  the  subject,  of 


AUTHOR  S    PREFACE.  xi 

which,  perhaps,  there  is  an  excess  at  present,  I  refer  to  the  flmiihar 
text-books.  In  this  part,  also,  it  was  my  endeavor  invariably  to  keep 
in  view  the  reqnirements  of  the  dentist,  and,  with  this  idea,  therefore, 
I  have  also  paid  especial  attention  to  the  growth  of  the  jaws  which  is 
connected  so  intimately  with  the  anomalies  in  the  position  of  the  teeth. 

1  have  endeavored  to  give  a  definite  idea  of  the  connection  between 
the  various  anomalies  of  formation,  whicli  are  so  important  to  the  den- 
tist, and  an  exposition  of  the  phenomena  of  development.  Many  gaps 
in  our  knowledge  of  the  latter  processes  are  yet  to  be  filled  up,  a  fact 
which  is  only  too  apparent ;  but  it  may  safely  be  said  that  many  of  the 
pathological  processes,  which  occur  in  the  later  years  of  life,  owe  their 
origin  to  an  abnormal  process  in  the  development  of  the  teeth. 

The  inflammations  which  came  Avithin  the  province  of  the  present 
work  have  been  considered  connectedly  ;  the  atrophies,  particularly  the 
changes  incident  to  old  age,  have  received  especial  study.  I  have 
taken  into  consideration  those  new-formations  which  have  their  seat  in 
the  jaws  and  stand  in  a  certain  relation  to  the  teeth,  in  addition  to 
those  which  belong  properly  to  the  teeth.  An  interstitial  growth  of 
bone  and  dentine  has  been  demonstrated,  especially  in  connection  with 
the  new-formations  in  the  teeth,  but  with  reference  to  other  new-for- 
mations also.  I  may  have  exposed  mj^self  to  criticism  by  classing 
caries  of  the  teeth  with  anomalies  of  the  secretions.  I  think,  however, 
my  exposition  of  the  subject  will  justify  mj^  course.  I  have  endeavored, 
as  far  as  our  present  knowledge  will  allow,  to  place  the  neuroses  upon 
a  scientific  basis. 

Although  the  book  forms  a  complete  work  by  itself,  I  have,  never- 
theless, continually  made  reference  to  the  "Atlas  to  the  Pathology  of 
the  Teeth,"  without,  however,  encroaching  upon  the  text.  The  Atlas 
and  the  Pathology  herewith  presented,  together  form  a  complete  whole, 
and  the  understanding  of  the  latter  will  be  promoted  essentially  by  the 
former.  All  the  illustrations  in  the  present  work  are  original  and  were 
drawn  upon  wood  by  Dr.  Ileitzmann,  of  Vienna,  with  the  rare  skill 
peculiar  to  him,  and  were  engraved  with  great  accuracy  by  Mr.  Flegel, 
of  Leipsic.  I  am  persuaded  that  they  will  render  valuable  aid  in  the 
appreciation  of  the  text.  The  explanation  of  each  figure  is  given  in 
detail  and  thereby  interruptions  in  the  text  are  avoided. 

In  closing,  I  hope  that  this  book,  which,  I  may  truly  say,  has  re- 
quired a  considerable  expense  of  time  and  labor,  may  meet  with  such  a 


XU  AUTHOR  S    PREFACE. 

favorable  reception  as  was  accorded  to  the  Atlas,  and  that  it  may  aid 
in  directing  more  attention  to  the  doctrine  Avhich  hitherto  has  been 
neglected  somewhat  as  a  whole,  although  portions  of  it,  to  be  snre, 
liave  been  elaborated. 

Carl  "Wedl. 
ViKNXA,  Xovembor  4iii,  1870. 


CONTENTS. 


PAGE 

Translator's  Preface, 5 

Author's  Preface, 9 

Introduction,       .      _ 17 


PART  I. 


ANATOMY  AND  PHYSIOLOGY. 


Genei-iil  Characters  of  the  Teeth,   . 

28 

Classification  of  the  Teeth,     .... 

30 

Description  of  the  Temporary  and  Permanent  Te 

eth. 

31 

Temporary  Teeth,  .         .         .         . 

38 

The  Hard  Tissues  of  the  Teeth,      . 

43 

Cement, 

51 

The  Pulp, 

54 

The  Gum, 

57 

The  Koot-Membrane,  Periosteum  of  the  Root, 

58 

Developnient  of  the  Teeth,     .... 

60 

First  Dentition,       ...... 

73 

Second  Dentition, 

76 

Third  Dentition, 

87 

Growth  of  the  Jaws, 

88 

PART  II. 

PATHOLOGY. 


I.  Irregularities  in  the  Formation  of  Teeth, 

1.  Irregularities  of  Size,  .... 

2.  Irregularities  of  Number,  .... 

Deficiencj^  of  Teeth,     .... 


98 

98 

99 

104 


XIV  CONTENTS. 

PAGE 

3.  Irregularities  of  Arrangement, 108 

A.  Irregularities  in   the   Arrangement  of  the  entire  Dental 

Arches,     .         .         .         .         .         .         .         .         .         .108 

B.  Irregularities  in  the  Position  of  the  separate  Permanent 

Teeth 112 

Central  Incisors,       ........  113 

Lateral  Incisors,       ........  114 

Canine  Teeth, 116 

Bicuspids  and  Molars, 118 

Irregularities  in  the  Position  of  the  Milk  Teeth,     .         .  121 

C.  Irregularities  in  the  Position  of  separate  Permanent  Teeth 

which  are  Imbedded  within  the  Jaw,      ....  122 

D.  Ketention  of  Teeth  without  Displacement,           .         .         .  127 

4.  Irregularities  of  Structure,         .         .         .         .         .         .         .130 

a.  Flexions  and  Torsions  of  the  Crowns  and  Roots,         .         .  130 

h.  Excessive  Growth  upon  the  Crowns  and  Boots,  .         .         .  134 

c.  Defective  formation  of  the  Crowns  and  Roots,    .         .         .  139 

d.  Blending  or  Fusion  and  Coalition  or  Concrescence  of  adja- 

cent Teeth, 147 

e.  Malformations,      .........  154 

II.  Inflammations, 176 

Pulp, 176 

Gum, 192 

Diseases  occasioned  by  the  First  Dentition,          ....  199 

Diseases  occasioned  by  the  Second  Dentition,       ....  201 

Root-Membrane, 204 

Alveolar  Abscess,          .........  216 

Nasal  Cavity  and  Antrum, 228 

III.  Atkophies, 232 

Pulp, 232 

Senile  Dentine,  ..........  242 

Cement^       ...........  244 

Resorption  of  Senile  Dentine  and  Cement,         ....  245 

Enamel, 246 

Surfaces  produced  upon  the  Crowns  by  Attrition,      .         .         .  247 

Gum, 254 

Root-Membrane  and  Alveolus,  .......  255 

Maxillary  Periosteum  and  Maxillary  Bones,     ....  257 

IV.  Hypertrophies, 271 

Cement,        ...........  271 

Root-Membrane,          .........  277 

Gum, 279 


CONTENTS.  XV 

PAGE 

V    New-Formations 284 

Pi'lp, 285 

New-Formations  of  the  Hard  Dental  Tissues,      ....  286 
Musket-balls  in  the  Teeth  of  Elephants,       .....  301 
New-Formations  of  Osseous  Substance  in  connection  with  Ab- 
scesses in  the  Ivory  of  the  Tusks  of  Elephants,        .         .         .  304 

Fractured  Teeth, 307 

Cement,  Osteomata,  Exostoses,      .......  312 

Koot-Membrane,   ..........  316 

Gum, 319 

Mucous  Membrane  of  the  Mouth,          ......  321 

Alveolar  Processes,        .........  322 

Cysts  of  the  Jaws,         .         .         .         .         .         .         .         .         .331 

Osteophytes  upon  the  Jaws,  ........  335 

Enostoses  in  the  Jaws, 337 

Chondromata  of  the  Jaws,    ........  339 

Fibromata  of  the  Jaws, 340 

Sarcomata  of  the  Jaws,          ........  343 

Gelatinous  Tumors,  Myxomata,    .......  348 

Carcinomata,          ..........  349 

Antrum, 351 

VI.  Anomalies  of  the  Secretions, 354 

Saliva, 354 

Coating  upon  the  Teeth. 357 

Tartar,  Odontolithus, 361 

Caries  of  the  Teeth, 367 

Appearances  presented  by  the  Enamel  in  Caries,        .         .         .  376 

Appearances  presented  by  the  Dentine  in  Caries,       .         .         .  384 

Appearances  presented  by  the  Cement  in  Carifes,        .         .         .  391 

Extension  of  Caries  to  the  Boots,        ......  392 

Caries  of  the  different  kinds  of  Teeth,        .....  393 

Frequency  of  Caries, 397 

Effects  of  Carious  Teeth  upon  the  rest  of  the  Body,  .         .         .  403 

Caries  of  Reinserted  Human  Teeth,   ......  404 

Caries  of  Teeth  made  of  Ivory  from  the  Hippopotamus,  .         .  406 

Experiments  upon  the  Teeth  with  Various  Substances,      .         .  407 

Caries  of  the  Teeth  of  Animals,          ......  410 

Theories  of  Caries, 411 

VII.  Neuroses, 426 

Alphabetical  Index, 445 


INTRODUCTION. 


If  it  be  asked,  with  i-eference  to  the  history  of  dental  science, 
Avhy  the  doctrines  of  the  latter  have  matured  at  a  comparatively 
late  period,  the  answer  is  obvious,  namely,  because  its  study 
was  not  pursued  systematically  as  that  of  a  natural  science. 
Until  about  the  middle  of  the  last  century,  dentistry  was  almost 
exclusively  in  the  hands  of  the  laity,  not  of  physicians,  and  was, 
and  is  at  the  present  time,  neglected  by  the  latter  as  a  sort  of 
stepchild  of  surgery.  The  so-called  dentists  of  former  times 
had  no  knowledge  of  the  discoveries  of  the  great  anatomists  of 
the  fifteenth  and  sixteenth  centuries ;  indeed,  it  was  not  pos- 
sible for  them,  since  they  did  not  have  access  to  any  scientific 
models,  and  consequently  knew  nothing  about  them.  They  took 
no  pains  to  determine  the  simplest  matters  of  fact ;  disputed  as 
to  the  number  of  teeth  possessed  by  men  and  women,  respec- 
tively. The  belief  was  prevalent  for  a  long  time  that  the  milk 
teeth  have  no  roots.  The  renowned  French  dentist,  P.  Fau- 
chard  (1728),  (Carabelli,  Geschichte  der  Zahnheilkunde  and 
Linderer's  Zahnheilkunde),  and  later,  Bourdet  (1757),  endeav- 
ored, upon  anatomical  grounds,  to  disabuse  men  of  tliis  errone- 
ous idea ;  nevertheless,  forty  years  afterwards,  I  am  sorry  to 
say,  we  read  in  German  writings  that  the  milk  teeth  have  no 
roots,  but  are  capable  of  giving  off  roots,  if  they  are  not  detached 
at  the  proper  time.  The  great  J.  Hunter,  Fox  and  his  pupils, 
Avere  the  first  to  follow  a  system  of  natural  science  and  to 
initiate  unprejudiced  and  trustworthy  methods  of  observation, 
while  Germany,  during  the  preceding  and  in  the  first  decade  of 
the  present  centurj^  took  scarcely  any  share  in  the  progress  of 
dental  science. 

If  we  call  to  mind  the  history  of  the  forceps,  we  now  wonder, 

2 


18  INTRODUCTION. 

and  with  reason,  tliat  people  ever  ventured  to  extract  teeth 
■without  having  informed  themselves  beforehand  with  regard  to 
the  construction  and  arrangement  of  the  crowns  and  roots  in 
the  jaw,  &c.  Indeed  it  is  the  fact,  that  they  ventured  only  with 
great  reluctance  to  extract  a  tooth  for  more  than  a  thousand 
years  after  Celsus.  Notwithstanding  the  manifold  improve- 
ments, during  the  preceding  and  commencement  of  this  century, 
in  the  art  of  extracting  teeth,  it  was  not  until  our  own  time, 
principally  through  the  exertions  of  J.  Tomes,  Richardson  and 
others,  that  the  mechanism  of  the  forceps  Avas  accurately 
adapted  to  the  separate  teeth,  in  the  upper  and  lower  jaw,  on 
the  right  and  left  side,  and  to  their  arrangement  in  the  jaw, 
so  that  now  there  is  danger  of  fracturing  the  tooth,  its  socket, 
or  the  jaw,  in  exceptional  cases  only. 

It  is  conceivable  that,  in  consequence  of  the  danger  attend- 
ing the  extraction  of  teeth,  a  great  variety  of  expedients  were 
employed  for  the  benefit  of  the  unfortunate  patients,  and  that 
attempts  were  made  to  ascertain  the  causes  of  the  pain.  In  the 
absence  of  all  anatomical  and  physiological  knowledge,  the 
gnawing  and  piercing  pains  seem  to  have  given  rise  to  the  idea 
of  the  presence  of  parasites.  The  fringes  of  the  thickened  peri- 
osteum of  the  root,  or  the  root  pulps,  which  remain  attached  to 
teeth  after  their  extraction,  may  have  given  weight  to  the  hy- 
pothesis that  worms  are  developed  within  the  tooth  and  give  rise 
to  the  pain.  Indeed,  it  was  said,  worms  might  originate  at  any 
part  per  generationem  cequivocam.  This  hypothesis  held  posses- 
sion of  men's  minds  during  the  seventeenth  century,  and  still 
prevails  among  the  common  people  whose  character  for  implicit 
belief  in  traditions  is  by  no  means  eradicated.  The  belief  in  the 
existence  of  the  worms  was  so  general  that,  in  1757,  J.  Ch. 
Schjiffier,  of  Regensburg,  published  a  monograph,  entitled  "  The 
Imaginary  Worms  of  the  Teeth,"  wherein  he  proved  that  the 
existence  of  these  worms  is  a  chimera,  and  that  the  so-called 
tooth-worms,  which  fall  from  the  teeth  after  fumioration  with 
winter-cherry  and  wax,  are  nothing  but  the  volatilized  germs  of 
the  winter-cherry  seed-corns.  Thus  dentistry  prolonged  a 
wretched  existence,  depending  for  its  support  upon  popular 
tradition. 


INTRODUCTION.  19 

The  instructors  in  the  old  universities  trod,  for  the  most  part, 
in  a  beaten  track  of  doctrine  which  was  based  upon  faith  in  au- 
thority, but  when,  in  the  study  of  the  natural  sciences  in  gen- 
eral, inquiries  were  instituted  with  reference  to  the  connection 
of  cause  and  effect  between  separate  phenomena,  and  the  latter 
were  subjected  to  the  most  searching  analysis  and  referred  to 
fundamental  laws  of  general  application,  then  the  natural 
sciences  made  such  comparatively  rapid  strides  that  they  soon 
invaded  every  branch  of  human  knowledge.  As  the  mass  of 
material  to  be  digested  accumulated,  the  necessity  of  a  further 
and  further  division  of  labor  in  the  fiehl  of  natural  sciences  be- 
came apparent,  and  from  this  principle  of  division  has  resulted, 
among  others,  the  branch  of  dental  science  ;  this  was  elevated  to 
the  rank  of  a  special  study,  and  demanded,  therefore,  special  in- 
struction, W'hich,  in  England  and  the  United  States  of  America 
particularly,  has  attained  a  high  degree  of  excellence.  During 
the  last  ten  years,  thanks  to  the  exertions  of  individuals,  den- 
tistry has  entered  upon  a  scientific  career  in  German}^,  and 
there  is  reason  to  expect  that  it  will  soon  be  rescued  from  the 
realms  of  mere  empiricism. 

While  we  recognize  fully  the  endeavors  of  those  of  former 
times  to  aid  their  suffering  fellow-beings  with  the  means  at  their 
command,  it  must,  however,  be  conceded  that  it  was  not  until 
modern  times  that  the  reach  of  thought  was  broad  enough  to 
enable  men  to  establish  a  truly  scientific  basis  for  a  rational 
system  of  therapeutics.  Anatomy  and  physiology,  the  guiding 
stars  of  pathology,  have  by  degrees  shed  their  salutary  light 
upon  dentistry,  and  afforded  an  insight  into  the  life  of  the  tooth, 
though,  to  be  sure,  it  is  only  partially  satisfactory.  Bearing 
this  in  mind,  I  have  deemed  it  advisable  to  preface  the  Pa- 
thology Avith  a  section  upon  Anatomy  and  Physiology. 


THE 


PATHOLOGY  OF  THE  TEETH. 


PAET   I. 

ANATOMY  AND  PHYSIOLOGY. 

The  dentist  is  occupied  specially  with  the  cavity  of  the  mouth, 
a  thorough  knowledge  of  which  is  indispensable  to  him,  and  by 
the  consideration  of  which,  from  his  standpoint,  much  is  eluci- 
dated which  the  anatomist  cannot  touch  upon  without  interfer- 
ing with  his  more  general  plan.  It  does  not  come  within  the 
scope  of  the  present  work  to  enter  into  full  anatomical  descrip- 
tions, but  the  object  in  view  necessitates  rather  references  to 
details  which  receive  only  slight,  if  any,  notice  from  the  anato- 
mist, but  which  acquire  importance  in  dentistry. 

With  regard  to  the  physiological  portion  of  our  subject,  which 
is  connected  so  intimately  with  the  anatomical  portion  that  the 
two  cannot  conveniently  be  considered  apart,  our  knowledge 
has  not  made  very  marked  progress  since,  in  the  investigations 
into  the  individual  life  of  the  tooth,  many  difficulties  are  to  be 
contended  with,  and  extensive,  subtile  researches  are  requisite. 
Many  of  the  latter  have  already  been  made,  but,  at  present, 
their  results  are  widely  scattered  and  do  not  yet  admit  of  in- 
corporation into  a  profitable  whole.  The  advances  made  in  our 
knowledge  of  the  laws  of  embryonic  development  have  indeed 
cleared  up  many  obscure  points,  yet  the  theoi-y  of  the  complex 
animal-cell-life  still  rests  upon  widely  diverging  hypotheses  and 
mostly  arbitrary  interpretations. 

The  bony  frameuwrk  of  tlie  cavity  of  the  mouth  is  formed, 


22  ANATOMY    AND    PUYSIOLOGY. 

laterally,  by  the  alveolar  portions  of  both  jaws,  and,  above,  by 
the  palatal  plates  of  the  upper  jaw  and  palate  bone. 

The  alveolar  process  of  the  superior  maxillary  hone  forms  a 
projection  from  the  inferior  portion  of  the  body  of  the  jaw,  in 
the  form  of  a  comb,  and,  upon  the  inside,  is  in  relation  with  the 
palatal  plates  of  the  upper  jaw  and  palate  bone.  It  incloses  a 
row  of  cells  which  are  arranged  in  the  form  of  an  elliptic  arch 
and  serve  for  the  reception  of  the  roots  of  the  teeth. 

Each  tooth-cell  {alveolus)  is  composed  of  a  finely  porous,  com- 
pact plate  of  bone  which,  when  it  is  perfectly  formed,  is  sunk 
into  the  spongy  tissue  of  the  jaw,  in  the  form  of  a  cul-de-sac  or 
funnel,  and,  towards  the  open  extremity,  comes  into  intimate 
relation  with  the  cortical  substance  of  the  bone.  At  the  closed 
extremity  of  the  cell,  there  are  a  few  quite  large  foramina 
which  lead  to  the  alveolar  canals,  and  serve  for  the  passage  of 
the  dental  nerves  and  vessels.  These  relations  may  be  demon- 
strated most  clearly  in  the  jaws  of  children  by  the  careful  re- 
moval of  the  facial  wall,  together  with  the  spongy  tissue,  so  that 
the  cells  and  their  delicate  attachments  to  the  cortical  substance 
of  the  bone  at  their  open  extremities  are  exposed  to  view.  The 
cells  then  are  presented  in  the  form  of  clearly  defined,  conical 

prolongations  of  compact  bony  tis- 
sue (Fig.  1).  Again,  if  longitud- 
inal sections  be  made  through  the 
teeth  and  jaw  of  an  adult  before 
he  has  attained  to  old  ag-e,  it  will 
be  seen  that  the  root  lies  within  a 
quite  firm  bony  capsule  with  thin 
walls,  Avhich  dips  down  from  the 
alveolar  border,  and  is  surrounded  by  a  very  lax,  spongy,  bony 
tissue. 

*  Fig.  1  shows  the  alveoli  of  milk  teeth  of  the  right  segment  of  the  upper 
jaw,  from  which  the  investing  spongy  bony  tissue  has  been  removed,  and  also 
the  rounded  alveolus  (a)  of  the  first  permanent  molar.  The  facial  wall  of 
the  alveoli  does  not  extend  so  far  downward  as  the  lingual  wall,  and  presents 
an  excavated,  crescentie  margin ;  the  third  or  lingual  roots  of  the  two  milk 
molars  do  not  appear  in  the  section.  The  posterior  external  root  of  the  second 
milk  molar  rests  upon  the  convex  surface  of  the  alveolus  which  incloses  the 
crown  of  the  first  permanent  molar.     Natural  size. 


SUPERIOR    MAXILLARY    BONE.  23 

The  number  of  sockets  corresponds  with  that  of  tlie  roots  of 
the  teeth.  Teeth  with  one  root  have  a  single  socket,  while  those 
with  more  than  one  root  have  sockets  composed  of  two  or  three 
cells,  according  to  the  number  of  roots.  As  the  cells  are  casts, 
as  it  were,  of  the  roots,  they  correspond  with  the  latter  in  form 
and  direction,  and  the  ridge-like  elevations  of  the  cells  fit  into 
the  furrows  in  the  roots. 

The  alveoli  are  separated  from  each  other  by  bony  septa, 
which  increase  in  thickness  towards  the  apices  of  the  former, 
and  upon  the  alveolar  border  present  a  few  foramina,  which  are 
most  conspicuous  in  the  jaws  of  young  persons,  for  the  passage 
of  the  interalveolar  vessels  and  nerves.  The  cells  of  the  com- 
pound alveoli,  moreover,  are  separated  from  each  other  by  ad- 
ditional septa  for  each  root.  Hence,  in  the  cells  for  the  upper 
teeth  with  three  roots  we  find,  in  addition  to  the  anterior  and 
posterior  primary  septa,  two  secondary  septa,  one  of  which  has 
an  antero-posterior  direction  and  the  other  -extends  from  the 
outside  towards  the  inside.  The  anterior  or  facial  festooned 
border  at  the  free  extremities  of  the  sockets  is  excavated  more 
deeply  than  the  posterior  or  lingual  border. 

The  border  of  the  alveolar  arch  of  the  upper  jaw  from  a 
young  adult,  when  viewed  from  the  facial  side,  presents  a  double 
curve,  namely,  one  with  a  downward  inclination,  from  behind  for- 
wards, with  the  convexity  directed  downwards,  and  one  extend- 
ing upwards  towards  the  anterior  segment  of  the  arch,  and  with 
its  concavity  directed  downwards.  Upon  the  lower  jaw  the  re- 
lations of  the  serpentine  curve  are  the  reverse  of  the  preceding, 
i.  e.,  the  convexity  of  the  upper  corresponds  to  the  concavity  of 
the  lower  arch.  This  undulatory  curve  is  scarcely  perceptible 
on  the  alveolar  arches  of  old  people  or  young  children. 

The  external  or  facial  wall  of  the  alveolar  portion  of  the 
upper  jaw  is  thinner  and  more  yielding  than  the  internal  or 
lingual  wall,  and  from  the  former  project  oblong  folds  which  are 
produced  by  the  subjacent  roots  of  the  teeth".  These  may  be 
felt  distinctly  even  during  life,  and  afford  some  evidence  with 
regard  to  the  size  and  direction  of  the  roots.  They  are  the  so- 
called /M^a  alveolaria.  Not  unfrequently  a  portion  of  the  alve- 
olar wall  is  wanting,  together  with  the  corresponding  portion  of 


24  ANATOMY    AND    PHYSIOLOGY. 

the  dental  socket,  and  the  root  of  the  tooth  is  exposed  in  the 
oblong  opening. 

The  body  of  the  upper  jaw  incloses  a  cavity  of  great  importance 
to  the  dentist  on  account  of  the  diseases  which  have  their  seat 
within  it.  Tliis  is  called  the  Maxillary  Simis  or  Antrum  of 
Higlimore ;  its  floor  is  situated  above  the  sockets  of  the  molars 
and  second  bicuspid,  and  its  roof  is  formed  by  the  inferior  por- 
tion of  the  wall  of  the  orbit.  The  anterior  and  posterior  walls 
are  formed  by  the  corresponding  surfaces  of  the  jaw.  The  in- 
ternal wall  towards  the  nasal  cavity  presents  an  aperture  Avhich 
communicates  with  the  middle  meatus  of  the  nose  and  is  con- 
tracted considerably  by  the  inferior  turbinated  bone  and  by  por- 
tions of  the  ethmoid  and  palate  bones.  The  floor  of  the  antrum 
frequently  presents  conical  processes,  which  are  occasioned  by 
the  projection  of  the  apices  of  the  roots  of  the  above-mentioned 
subjacent  teeth,  and  also  one  or  two  more  or  less  prominent  lam- 
ina by  which  the-  bottom  of  the  cavity  is  divided  into  compart- 
ments. The  root  of  the  second  bicuspid  tooth  is  situated  be- 
neath the  anterior  smaller  division  of  the  cavity.  The  antrum 
belongs  to  the  system  of  communicating  cavities  which  are  lined 
by  the  nasal  mucous  membrane,  and,  in  common  with  which,  it 
is  frequently  the  seat  of  disease;  it  forms  a  portion  of  the 
respiratory  apparatus. 

The  inferior  maxillary  hone,  the  loiver  jaiv,  is  curved  in  the 
form  of  a  parabola,  and  consists  of  a  body  and  two  extremities; 
the  latter  ascend  in  vertical  planes  and  are  called  the  rami  or 
branches.  Both  the  body  and  the  rami  present  for  examination 
an  external  or  facial  and  an  internal  or  lingual  surface,  directed 
towards  the  cavity  of  the  mouth.  On  the  external  surface  of 
the  body,  equidistant  from  the  median  line  on  either  side,  is  a 
roundish,  occasionally  transversely  divided  foramen  which  com- 
municates with  the  inferior  dental  canal,  and  is  called  the  an- 
terior or  external  orifice  of  the  latter  {foramen  mentale).  It  is 
situated  six  to  ten  millimetres  below  the  alveolar  border,  usually 
in  a  perpendicular  line  drawn  between  the  first  and  second  bi- 
cuspids, and  not  infrequently  a  little  more  anteriorly  or  pos- 
teriorly, beneath  the  first  or  second  bicuspid. 

Extending  obliquely  upwards  from  the  vicinity  of  the  first 


INFERIOR    MAXILLARY    BONE.  25 

molar  is  a  well-marked  ridge,  the  external  oblique  line,  which  is 
continnous  with  the  anterior  border  of  the  ramus,  and  near  the 
posterior  segment  of  the  alveolar  process  is  bounded  by  a  shaUow 
groove.  The  corresponding  portion  of  the  external- wall  of  the 
lower  jaw  is  rendered  thicker  and  less  yielding  by  this  promi- 
nent ridge,  a  condition  of  practical  importance  to  the  dentist. 

The  internal  surface  presents,  opposite  the  median  line,  a 
rough  eminence,  the  internal  mental  process  (prominentia  men- 
talis  int.).  Upon  either  side  of  this  process  commences  a  ridge, 
the  inte7-nal  oblique  line,  which  extends  obliquely  upwards  towards 
the  molar  teeth,  and  serves  to  give  strength  to  the  alveolar  pro- 
cess upon  the  lingual  side  of  the  jaw,  and  for  the  attachment  of 
muscles. 

The  inferior  border  of  the  lower  jaw  is  rounded,  and  above  it 
rises  the  alveolar  process,  which  in  adults  contains  sixteen  al- 
veoli for  the  reception  of  the  teeth.  The  last  three  alveoli  on 
either  side  are  compound,  each  being  divided  into  two  secondary 
cells  by  an  additional  septum.  The  alveolar  process  of  the 
lower  jaw  describes  a  parabolic  curve,  and  its  posterior  extremi- 
ties are  separated  by  a  wider  interval  than  are  those  of  the 
upper  jaw.  This  inequality,  which  would  not  permit  the  mutual 
adaptation  of  the  teeth,  is  compensated  for  by  the  fact  that  the 
superior  alveolar  process  has  an  outward  inclination  throughout 
its  whole  extent,  while  the  lateral  portions  of  the  inferior  pro- 
cess are  inclined  inwards,  and  hence  the  teeth  preserve  a  corres- 
ponding inclination.  As  has  already  been  stated,  the  facial 
wall  of  the  superior  alveolar  process  is  thinner  and  more  elastic 
than  the  lingual,  but  this  is  true  of  the  facial  wall  in  the  lower  jaw 
only  as  far  as  the  region  of  the  first  molar,  beyond  which  point 
the  liniTual  wall  is  thinner  than  the  facial.  The  concavities  of 
the  festooned  alveolar  border  of  the  lower  jaw  are  directed  up- 
wards, and  the  septa  between  the  alveoli  project  beyond  the 
level  of  the  latter. 

The  rami  of  the  inferior  maxillary  arch,  forming  obtuse  angles 
with  the  body,  extend  obliquely  upwards  and  a  little  outwards, 
and  each  terminates  in  two  processes  separated  by  a  crescentic 
notch ;  the  anterior  or  coronoid  process  rises  behind  the  last 
alveolus,  frequently  encroaches  upon  the  latter   to   a   consider- 


2G  ANATOMY    AND    PHYSIOLOGY. 

able  degree,  so  tluit  its  lingual  surface  even  not  infrequently 
renders  the  upper  -wisdom  tooth  difficult  of  access  ;  the  posterior 
or  condyloid  process  is  of  much  greater  importance  ;  it  terminates 
in  a  small,  cylindriform^  convex,  articular  condyle,  the  long 
axis  of  ^vhich  is  transverse.  The  long  axes  of  the  two  condyles 
are  not  horizontal,  but  are  inclined  somewhat  obliquely  upwards 
and  backwards,  so  that  if  prolonged  they  would  meet  at  an  angle 
of  about  150°.  Articular  condyles,  however,  are  met  with 
whose  long  axes  are  nearly  horizontal. 

The  lingual  surface  of  the  ascending  ramus  presents  the  pos- 
terior or  internal  orifice  of  the  inferior  dental  canal,  partially 
covered  in  front  by  a  small  bony  phite,  the  spinous  process  of 
the  lower  jaw.  The  inferior  dental  canal  commences  at  this 
opening,  and,  decreasing  in  size,  extends  through  the  body  of 
the  jaw  beneath  the  alveoli,  terminating  at  the  mental  foramen, 
and  is  lined  by  a  thin  lamella  of  bone,  finely  porous  upon  its 
inner  surface. 

The  articulation  of  the  loiver  jaw,  by  means  of  which  the  ap- 
proximation of  the  two  jaws  is  effected,  has  recently  been  made 
the  subject  of  special  investigation  by  C.  Langer.*  The  ar- 
ticular or  glenoid  fossa  of  the  temporal  bone  is  formed  partly 
by  the  squamous  portion  and  partly  by  the  vaginal  process  or 
tympanic  lamina  of  the  latter,  and  is  smooth  only  upon  its 
anterior  portion.  In  front  of  the  fossa  is  the  eminentia  articu- 
lar is,  the  whole  of  which  is  concerned  in  the  formation  of  the 
joint,  and  usually  is  obliquely  disposed.  The  interarticular 
cartilage  (7?ieni8Ciis  interartic^daris)  is  a  biconcave  plate  which 
is  inserted  between  the  articular  eminence  above  and  the  con- 
dyle below,  and  is  connected  with  both  bones.  The  edges  of  its 
smooth  surfaces  are  attached  upon  either  side  to  the  articular 
capsule,  so  that  the  joint  is  divided  into  two  cavities.  The  only 
proper  ligament  of  the  joint  is  situated  externalh%  the  iiga- 
mentum  laterale,  which  is  attached  above  to  the  root  of  the  zy- 
goma and  below  to  the  neck  of  the  lower  jaw. 

The  mobility  of  the  lower  jaw  is  limited.  The  movements  of 
the  two  joints  are  simultaneous  and  take  place  in  three  direc- 

*  Sitzungsberichteder  Wiener  Akademie,  18G0,  and  Lehrb\)ch  der  mensch- 
liclien  Anatomie,  1865. 


MOVEMENTS    OF    THE    LOWER    JAW.  27 

tions,  namely,  forwards  or  backwards  (sagittal),  from  side  to 
side  (horizontal),  and  downwards  (frontal).  In  the  latter,  the 
articular  condyle  glides  upon  the  articular  eminence  and  the 
chin  is  moved  downwards  in  the  arc  of  a  circle. 

The  movements  in  mastication  are  accomplished  by  four  pairs 
of  powerful  muscles,  two  of  which  are  attached  to  the  external, 
and  two  to  the  internal  surface  of  each  ramus  of  the  lower  jaw. 
They  are  the  masseter,  temporal,  external,  and  internal  ptery- 
goid muscles.  C.  Langer*  investigated  their  actions,  which  he 
describes  as  follows:  "The  masseter,  temporal,  and  internal 
pterygoid  muscles  elevate  the  jaw  and  press  the  lower  dental 
arch  against  the  upper.  Their  only  antagonists  are  the  hyoid 
muscles  and  the  platysma.  The  external  pterygoid  exerts  no 
action  in  a  vertical  direction,  but  draws  the  jaAv  and  the  men- 
iscus forwards  in  a  horizontal  plane  and  assists,  therefore,  in 
the  forcible  opening  of  the  mouth  ;  hence,  in  the  latter  respect, 
it  is  an  antagonist  of  the  first  mentioned  muscles  and  cannot 
act  in  unison  y/ith  them  except  in  moving  the  jaw  forward  when 
it  is  closed.  On  the  other  hand,  the  three  elevators  are  re- 
quired to  move  the  jaw  backwards,  since  their  action  has  a  ten- 
dency in  a  direction  from  in  front  backwards  and  in  a  horizontal 
plane.  Symmetrical  contractions  give  rise  to  the  sagittal 
movements ;  asymmetrical  movements,  to  either  side,  require 
the  contraction  of  the  muscles  upon  one  side  alone,  and,  as  it 
appears,  the  action  of  the  external  pterygoid  is  the  principal 
element  in  the  production  of  this  movement." 

The  three  principal  movements  of  the  lower  jaw  admit  of  an 
endless  variety  of  modifications  in  which  the  different  kinds  of 
teeth  variously  participate.  As  a  general  rule,  the  movements 
of  the  front  teeth  are  more  extensive  than  those  of  the  back 
teeth.  In  the  lateral  movement,  the  teeth  of  one  half  of  the 
lower  jaw  are  displaced  to  the  outside  of  the  corresponding 
teeth  of  the  upper  jaw,  while  the  teeth  of  the  other  segment  are 
removed  to  an  equal  distance  towards  the  median  line.  The 
extent  of  the  lateral  movements  of  the  teeth  bears  a  definite  re- 
lation to  the  construction  of  the  articulation  of  the  lower  jaw, 
and   is   diminished  with   the   more    horizontal    position    of   the 


*  Anatomie  S.  238. 


28  ANATOMY    AND    PHYSIOLOGY. 

articular  condyle.  In  the  latter  cases,  approximation  of  the 
jaws  is  effected  Avith  the  teeth  more  nearly  in  a  perpendicular 
plane.  The  difference  in  the  extent  of  the  movements  of  the 
front  and  back  teeth,  respectively,  is  most  noticeable  in  the 
frontal  movement,  while  in  the  sagittal  it  is  scarcely  perceptible. 

The  three  different  movements  employed  in  mastication  pass 
into  each  other,  but  these  transitions  are  impossible  while  any 
one  movement  is  exercised  to  its  maximum  degree.  In  biting, 
the  frontal  movement  is  employed;  in  cutting,  the  sagittal,  and 
in  triturating  the  food,  all  three  movements  occur  in  rapid 
succession. 

The  entire  mechanism  of  the  act  of  mastication  acquires  a 
still  more  complicated  character  when  the  undulatory  curves 
and  the  inclinations  of  both  the  upper  and  lower  rows  of  teeth 
are  taken  into  consideration.  In  consequence  of  these,  the 
movements  of  the  separate  teeth  are  variously  modified.  The 
mechanism,  also,  is  advantageous  for  the  purpose  of  fixing  the 
morsels  which  are  to  be  triturated. 

General  Characters  of  the  Teeth. — All  the  teeth  may 
be  considered  as  wedges.  These  assume  the  most  varied  forms 
in  the  animal  kingdom,  and  occur  in  the  form  of  chisels,  sharp- 
pointed  or  blunt,  narrow  or  broad,  long  or  short,  rounded  or 
laterally  compressed  cones  and  plates ;  their  forms  are  either 
simple  or  compound  ;  the  long  conical  teeth,  in  some  cases,  serve 
as  weapons  of  offence  and  defence.  By  the  interlocking  of  the 
wedges  of  the  lower  jaAV  with  those  of  the  upper,  and  the  pow- 
erful action  of  the  muscles  of  mastication,  solid  articles  of  food 
are  crushed.  Portions  which  escape  uncrushed  are  replaced 
again  between  the  wedges  by  means  of  the  action  of  the  tongue 
and  the  muscles  inserted  into  the  sides  of  the  mouth.  By  these 
means,  assisted  by  the  mucous  and  salivary  secretions  which  are 
abundant  during  the  proce'ss  of  mastication,  the  solid  food  is 
converted  to  a  pulp  suitable  for  deglutition. 

The  specific  gravity  or  density  of  the  teeth  varies  considerably. 
At  my  request.  Dr.  B.  Kopezky  examined  sections  of  fourteen 
teeth,  four  deciduous  and  ten  permanent  teeth,  with  reference 
to  this  point.  In  the  former,  the  density  varied  from  1.09  to 
2.17  ;  in  the  permanent  teeth  he  found  a  variation  between  1.98 


CLEAVAGE    OF    THE    TEETH.  29 

and  2.53,  amounting,  therefore,  to  0.55.  The  lowest  sp.  gr.  -was 
afforded  by  a  much  worn  upper  molar  with  horny  translucent 
roots  and  containing  a  dentinal  new-formation  which  completely 
filled  the  pulp-cavity  ;  the  greatest  density  was  found  in  a  much 
worn  bicuspid.  The  permanent  teeth  showed  an  average  density 
of  2.25.  These  summary  statements,  based  upon  the  examina- 
tion of  a  small  number  of  teeth,  cannot  be  regarded  as  conclu- 
sive, and  are  merely  intended  as  an  incentive  to  more  extended 
investigations  with  reference  to  varieties  in  individuals  and  at 
different  ages. 

The  hardness  of  the  dentine  of  human  teeth  is  placed  by 
Kopezky  between  5  and  6  in  Mob's  scale,*  i.  e.,  between  apatite 
and  felspar  ;  the  enamel,  which  emits  a  spark  with  steel,  ranks 
with  7  in  the  order  of  hardness. 

The  property  of  cleavage  may  be  demonstrated  in  the  crowns 
and  roots  of  teeth  by  means  of  the  vice,  and  in  teeth  which  have 
been  dried  and  treated  for  a  considerable  time  with  dilute  hydro- 
chloric acid ;  they  split  in  certain  directions  Avhich  are  deter- 
mined by  the  fact  of  their  possessing  single  or  multiple  papillary 
elevations.  Incisors,  especially  the  hard  and  brittle  ones  of  old 
people,  are  well  adapted  to  show  this  property ;  it  is  not  an  un- 
common occurrence  for  these  to  break  into  median  and  lateral 
halves,  merely  from  compression  exercised  with  slowly  increased 
force  upon  the  prominent  portions  of  the  facial  and  lingual  sur- 
faces. A  similar  division  of  round,  straight  roots  may  be 
effected,  but  this  is  impossible  with  curved  roots,  as  will  be  evi- 
dent, except  in  those  in  which  the  curve  is  very  slight.  Crowns 
which  are  flattened  upon  either  side  split  in  a  direction  corres- 
ponding with  the  greatest  transverse  diameter.  A  case  came 
under  my  observation  in  which  the  cleavage  of  all  the  teeth  in 
the  lower  jaw  of  a  large  dog  Avas  shown  in  a  very  marked 
manner.  The  lower  jaw  was  dried  and  placed  in  dilute  hydro- 
chloric acid ;  decalcification  ensued  slowly  and,  finally,  the  pre- 
viously scarcely  perceptible  cracks  in  the  enamel  became  gaping 

*  Moll's  scale  of  hardness  is  the  following :  1,  talc;  2,  gypsum  or  rock 
salt;  3,  calc  spar  (or  any  cleavable  variety)  ;  4,  fluor  spar  ;  5,  apatite  (crys- 
tallized);  (3,  felspar  (any  cleavable  variety);  7,  limpid  quartz;  8,  topaz;  9, 
sapphire  or  corundum  ;   10,  diamond. — Trs. 


30  ANATOMY    AND    PHYSIOLOGY. 

fissures,  extending;  to  the  bottom  of  the  crowns.  The  croAvns  of 
the  incisors  Avere  separated  into  symmetrical  median  and  lateral 
halves,  those  of  the  canines,  into  facial  and  lingual  halves,  and 
the  coronal  denticles  of  each  molar  were  divided  into  equal  seg- 
ments from  their  apices  to  their  bases. 

The  cracks  or  fissures,  which  are  observed  frequently  in  the 
enamel  during  life  and  are  considered  at  length  in  the  subse- 
quent pages,  sometimes  occur  in  the  above-mentioned  planes. 
The  reason  for  the  splitting  upon  the  median  line  is  to  be  found 
in  the  symmetrical  development  of  the  two  halves  of  the  tooth. 

The  teeth,  together  with  the  bony  tissue  partially  investing 
them,  have  a  high  degree  of  elasticity,  in  consequence  of  which 
they  may  be  subjected  to  marked  compression  and  still  return 
to  their  previous  condition  upon  the  removal  of  the  source  of 
the  latter;  these  physical  properties  appertain  to  the  dentine  in 
particular,  which,  in  addition  to  a  solid  structure,  presents  a 
delicacy  of  texture  that  admits  of  a  high  degree  of  tension. 

Classification  of  the  Teeth. — The  teeth  present  an  enam- 
elled and  a  non-enamelled  portion  ;  the  former  is  visible  in  the 
cavity  of  the  mouth,  and  is  called  the  crown  ;  the  latter  is  Avedged 
in  the  alveolus  and  is  called  the  root ;  the  portion  between  these 
two  is  described  commonly  as  the  neck.  The  discrimination  of 
the  neck  of  the  tooth,  however,  is  more  practical  than  it  is 
theoretically  correct,  since  the  neck  cannot  be  determined  ex- 
cept Avhile  the  tooth  is  implanted  in  the  jaw;  it  is  really  that 
portion  of  the  root,  just  above  the  edge  of  the  socket,  which  is  in- 
vested by  the  gum.  Upon  a  detached  tooth,  then,  that  portion 
may  be  designated  as..the  peck  Avhich  is  in  immediate  proximity 
to  the  terminal  border  of  the  enamel.  The  distinction  of  this 
portion  is  of  practical  importance  to  the  dentist,  since  he  applies 
his  instrument  to  this  part  in  the  extraction  of  teeth. 

The  classification  of  the  teeth  is  based  upon  their  locality, 
duration,  and  external  form.  In  reference  to  their  locality'',  the 
teeth  are  divided  into  those  of  the  upper  and  those  of  the  lower 
jaw ;  the  former  being  called  the  upper,  and  the  latter  the  loioer 
teeth. 

The  human  race  is  supplied  Avitli  two  sets  of  teeth  ;  those 
which  first  make  their  appearance  exercise  their  functions  during 


CLASSIFICATION    OF    THE    TEETH.  31 

a  fe^Y  years  only,  while  the  second  set  is  intended  for  service 
during  the  remainder  of  life;  hence,  in  reference  to  their  dura- 
tion, they  are  divided  into  milk,  temporary  or  deciduous,  and 
permanent  teeth.  The  milk  teeth  are  twenty,  and  the  perma- 
nent teeth  thirty-two  in  number;  twenty  of  the  latter  occupy 
the  places  of  the  previous  milk  teeth,  and  are  termed  permanent 
renewed  or  substituted  teeth,  in  contradistinction  to  the  twelve 
which  have  no  predecessors,  and  therefore  are  described  as  per- 
manent  unreneived  teeth. 

It  is  customary  with  dentists  to  divide  the  permanent  teeth 
into  four  kinds,  according  to  their  form,  namely:  incisors, 
canines,  Mcuspids,  and  molars.  In  anatomical  manuals,  fre- 
quently only  three  kinds  are  distinguished,  incisors,  canines, 
and  grinders  or  molars;  the  latter  being  divided  into  small  and 
large  molars.  Hunter,  however,  divided  those  previously  called 
grinders  into  two  kinds,  bicuspids  and  multicuspids,  upon  ana- 
tomical and  physiological  grounds,  and  since  that  time  this 
more  rational  nomenclature  has  been  adopted  by  dentists.  The 
milk  teeth  are  divided  into  incisors,  canines,  and  molars,  but  it 
is  to  be  borne  in  mind  that  the  latter  differ  in  respect  of  their 
construction  from  their  permanent  successors,  and  are  to  be 
classed  rather  with  the  permanent  unrenewed  molars  and,  there- 
fore, they  are  described  sometimes  by  English  dentists  as  tem- 
porary multicuspids  or  molars. 

The  following  surfaces  are  distinguished  usuall}^  upon  the 
teeth  :  facial  (labial  or  buccal),  anterior  or  external,  and  lingual, 
posterior,  or  internal.  The  contiguous  surfaces  of  adjacent 
crowns  receive  different  names  from  authors:  inner  and  outer, 
anterior  and  posterior,  medial  and  lateral,  or  mesial  and  distal.* 

Description  of  the  Temporary  and  Permanent  Teeth. — 
It  is  convenient  to  commence  with  the  description  of  the  per- 
manent  teeth,  since,  in  this  Avay,  that  of  the  milk  teeth  will  be 
shortened  considerably. f 

*  Comp.  Tomes's  System  of  Dental  Surgery,  1859,  p.  38. 

t  Carabelli  (Anatomic  des  Mandes,  1841)  was  the  first  to  make  extended 
investigations  into  the  structure  of  the  teeth,  witli  reference  to  the  needs  of 
the  dentists.  E.  Miihlreiter  has  recently  published  a  minute  description  of 
the  human  teeth  with  special  reference  to  the  requirements  of  mechanical 
dentistry.     (Leipsic,  1870.) 


32  ANATOMY    AND    PHYSIOLOGY. 

The  incisors,  considered  collectively,  present  common  pecu- 
liarities;  they  have,  namely,  a  wedge,  or  shovel-shaped  crown 
and  two  inclined  surfaces  which  form,  hy  their  junction,  a 
cutting  edge;  the  anterior  or  labial  surface  is  slightly  convex, 
the  lingual  or  posterior  presents  a  corresponding  concavity  ;  the 
lateral  surfaces  are  thin  and  triangular  in  shape;  the  enamel 
cap  extends  to  a  greater  distance  towards  the  root  upon  the 
labial  and  lingual  than  it  does  upon  the  lateral  surfaces.  The 
cutting  edge  of  the  crown  in  recently  cut  incisors  always  pre- 
sents three,  more  or  less  prominent  eminences,  the  middle  one 
projecting  the  most.  These  are  short  and  blunted,  and  disap- 
pear as  soon  as  the  teeth  are  brought  into  use.  They  have 
single  roots. 

Upper  incisors. — These  are  larger,  more  convex  upon  their 
labial,  and  more  concave  on  their  lingual  surfaces,  and,  in  gen- 
eral, have  a  more  rounded  form  than  the  lower  incisors.  Their 
labial  surfaces  increase  in  breadth  towards  the  cutting  edge,  and 
are  convex  in  each  direction.  The  transverse  convexities  of 
the  teeth  upon  the  right  and  left  side  respectively  face  in  oppo- 
site directions,  so  that  the  surfaces  of  the  teeth  upon  the  right 
side  are  directed  to  the  right ;  those  upon  the  left  side,  to  the 
left,  and  in  this  way  the  anterior  convexity  of  the  dental  arch 
is  produced.  The  lingual  surfaces  present  a  corresponding 
arrangement  of  the  arches.  A  pit  in  the  enamel  is  met  with 
frequently  in  the  upper  portions  of  the  lingual  surfaces,  par- 
ticularly of  the  lateral  incisors ;  this  communicates  with  a  groove, 
and  frequently  is  the  seat  of  the  commencement  of  caries,  though 
in  this  connection  it  is  very  likely  to  be  overlooked. 

The  crowns  of  the  right  and  left  upper  incisors,  in  addition  to 
the  above-mentioned  arrangement  of  their  arches,  are  distin- 
guished by  their  angles.  The  two  angles  formed  by  the  junc- 
tion of  the  gradually  narrowing  lateral  surfaces  with  the  cutting 
edge,  are  not  uniform.  Upon  the  right  incisors,  the  distal 
lateral  surfaces  join  the  corresponding  incisive  edges  by  means 
of  a  gentle  curve,  while  the  mesial  lateral  surf<ices  and  the 
edges  form  sharp  right  angles.  Upon  the  left  incisors  the  re- 
lations of  the  angles  are  exactly  the  reverse  of  the  latter  ;  hence, 
from  these  data  alone,  it  is  possible  to  distinguish  a  right  or  left 


DESCRIPTION    OF    THE    PERMANENT    TEETH.  33 

incisor.  Well-formed  incisors  have  single  roots,  -which  are  coni- 
cal, straight,  and  afford  circular  transverse  sections.  Now  and 
then  their  terminal  portions  are  bent,  in  which  cases  the  apex 
is  directed  posteriorly  towards  the  adjacent  tooth,  i.  e.,  the  apex 
of  the  right  central  towards  the  right  lateral,  that  of  the  left  cen- 
tral towards  the  left  lateral,  &c.  This  observation  is  applicable 
not  only  to  the  upper  incisors,  but  to  all  the  permanent  teeth. 

The  lateral  upper  incisors  present,  in  general,  all  the  charac- 
teristics of  the  centrals,  but  differ  from  them,  however,  in  the 
relation  of  the  length  to  the  breadth:  while  they  differ  but  little 
in  length,  the  breadth  of  the  laterals  is  a  third  less  than  that 
of  the  centrals,  so  that  the  former  present  a  more  slender  ap- 
pearance than  the  latter;  their  edges,  moreover,  are  not  so 
sharp,  and  they  are,  generally,  more  rounded  than  the  latter. 

The  connection  of  the  upper  incisors  with  the  alveolar  pro- 
cess may  be  shown  by  means  of  vertical  sections 
through  the  middle  of  the  tooth  and  jaw  (Fig.  2). 
The  anterior  or  facial  wall  of  the  compact  process 
is  found  to  be  much  thinner  than  the  lingual,  and 
the  latter  becomes  thicker  from  below  upwards. 

Loiver  Incisors. — These  are  smaller  than  the 
upper,  the  convexities  and  concavities  of  theii^-  sur- 
faces are  less  decided;  they  do  not  present  the 
gentle  curve  at  the  outer  or  lateral  angle  of  the 
incisive  edge,  and  consequently  lack  this  element 
of  distinction  between  the  teeth  of  the  right  and  left  sides. 
The  laterals,  moreover,  are  broader  than  the  centrals,  differing 
in  this  respect  from  the  upper  teeth.  The  side  to  which  a  lower 
incisor  belongs  can  only  be  determined  by  the  curvature  of  its 
surfaces,  which,  as  observed  above,  is  not  very  decided,  and  the 
distinction  therefore  requires  considerable  practice.  It  is  more 
difficult  to  distinguish  the  centrals  than  the  laterals.  The  roots 
are  single,  flattened  upon  the  medial  and  lateral  surfaces,  and 
grooved  longitudinally. 


*  Fig.  2.— Vertical  section  through  the  middle  of  a  right  upper  central 
incisor,  showing  the  connection  of  the  latter  with  the  alveolar  process;  be- 
hind the  latter  appears  the  incisive  canal  in  an  oblique  position.  Natural 
size. 

3 


34  ANATOMY    AND    PHYSIOLOGY. 

Canines  {denies  cuspidati). — These  have  a  strong  club-shaped 
crown,  terminating  in  a  point.  The  hibial  surface  is  convex 
and  divisible  into  two  equal  portions,  a  medial,  more  convex, 
directed  towards  the  lateral  incisor,  and  a  lateral,  more  flattened, 
directed  towards  the  first  bicuspid.  The  lingual  surface  is  slightly 
concave,  and  inclined  towards  the  labial.  The  lateral  surfaces 
of  the  crown  also  are  convex  ;  the  medial,  towards  the  lateral 
incisor,  is  moderately  arched,  the  lateral,  towards  the  first  bi- 
cuspid, is  still  more  convex,  the  latter  forming  a  blunt  protuber- 
ance. The  canines  have  a  single  root  which  is  distinguishable 
from  the  roots  of  the  rest  of  the  teeth  in  the  set  by  its  greater 
length ;  the  roots  of  the  upper  canines  are  somewhat  longer 
than  those  of  the  corresponding  lower  teeth  ;  the  axes  of  the 
roots  describe  a  slight  curve  with  the  convexity  directed  towards 
the  lips.  The  apices  of  the  roots  are  inclined  more  or  less 
towards  the  posterior  adjacent  tooth.  The  roots  are  flattened 
somewhat  upon  either  side  and  grooved  ;  the  lateral  grooves 
upon  those  of  the  lower  teeth  are  deeper  than  those  upon  the 
upper  teeth.  The  root  canals  of  the  upper  canines  are  oval  in 
shape,  those  of  the  lower  are  more  compressed  from  either  side 
and  present  a  more  or  less  marked  incurvation. 

The  right  and  left  canine  teeth  are  distinguished  by  the 
greater  arch  of  the  medial  halves  of  the  labial  coronal  surfaces, 
which  look  toward  the  lateral  incisors,  and  especially  also  by 
the  curvature  of  the  labial  surfaces,  which  is  in  opposite  direc- 
tions upon  the  teeth  of  either  side. 

Bicuspids  {denies  bieuspidati). — These  have  crowns  essentially 
diff"erent  from  those  of  the  teeth  which  have  already  been  de- 
scribed. The  masticating  surface  is  uneven,  and  is  divided  by 
a  groove  which  extends  from  the  front  to  the  back,  into  two 
pointed  tubercles  or  cusps,  of  which  the  outer  is  the  larger. 
The  masticating  surface  of  the  crown  is  bounded  by  four  sur- 
faces, which  run  into  one  another  without  forming  edfjes.  The 
outer  or  buccal  and  inner  or  lingual  surfaces  are  rounded. 
The  lateral  surfaces,  which  comprise  the  anterior  (medial  or 
mesial)  and  posterior  (lateral  or  distal),  are  somewhat  flattened. 
The  crowns  of  all  bicuspids  are  slightly  inclined  from  before 
backwards.     The  buccal  or   external   surface  of  the  crown   of 


DESCRIPTION    OF    THE    PERMANENT    TEETH.  35 

each  upper  bicuspid  is  indicated  by  the  greater  convexity  of  its 
anterior  or  medial  segment,  while  its  posterior  is  more  flattened 
and  inclined,  and  by  the  fact  that  the  posterior  coronal  surface 
is  somewhat  more  convex  than  the  anterior.  Their  roots  are 
more  or  less  flattened,  often  single,  smooth,  and  frequently  aiij 
traversed  in  their  length  by  a  groove,  and  sometimes  are  divided 
more  or  less  deeply  at  their  extremities,  this  division  occurrino- 
more  frequently  in  the  first  than  in  the  second  bicuspid. 

The  crown  of  the  first  lower  bicuspid  resembles  that  of  the 
adjacent  canine  tooth,  inasmuch  as  the  outer  or  buccal  cusp 
projects  more  than  the  inner,  and  hence  the  masticating  surface 
has  a  more  oblique  direction  toward  the  median  line.  The 
second  lower  bicuspid  has  a  larger,  more  spherical  crown,  and 
both  cusps  are  of  nearly  equal  size,  so  that  the  first  and  second 
lower  bicuspids  may  easily  be  distinguished.  The  inner  cusp 
is  sometimes  furroAved,  giving  the  appearance  of  two  inner  cusps 
Avith  corresponding  depressions.  Transverse  sections  of  the 
lower  bicuspids  are  oval  in  shape. 

The  masticating  surfaces  of  the  upper  bicuspids  are  divided 
by  a  deep  groove  extending  from  before  backwards ;  the  outer 
cusp  is  somewhat  larger  and  more  prominent  than  the  inner, 
which  is  rounded  on  the  lingual  surface. 

Not  infrequently  the  first  and  second  upper  bicuspids  cannot 
be  distinguished  when  separated  from  the  jaw,  but  those  of  the 
right  or  left  side  may  be  recognized  by  the  more  decided  curve 
of  the  anterior  segment  of  the  facial  surface  of  the  crown,  by 
the  more  flattened  and  larger  posterior  segment  of  the  same 
surface,  and  by  the  larger  buccal  cusp  of  the  crown. 

The  molars  have  a  quadrilateral  crown,  surmounted  by  several 
tubercles  or  cusps,  and  tw'O  or  three  roots.  The  upper  molars 
have  irregularly  four-sided  rhomboidal  crowns.  The  outer  and 
inner  coronal  surfaces  are  convex,  the  latter,  indeed,  to  a  consid- 
erable degree ;  the  surfaces  looking  tOAvard  the  adjacent  croAvns 
are  flattened.  The  upper  surface  is  surmounted  generally  by 
four  tubercles  or  cusps,  separated  from  each  other  by  three 
grooves.  One  extends  from  the  anterior  to  the  posterior  mar- 
gin of  the  crown,  and  forms  a  continuation  of  the  groove  upon 
the  upper  surfaces  of  the  bicuspid  teeth.     The  other  two  extend 


36  ANATOMY    AND    PHYSIOLOGY. 

from  the  middle  of  the  outer  and  inner  margins  of  the  crown 
respectively  without  coming  in  contact ;  the  outer  furrow  is  di- 
rected obliquely  forward  and  the  inner  obliquely  backward, 
forming  a  flattened  bow.  In  this  way  four  tubercles  are  formed, 
of  which  the  front  pair  is  the  larger.  The  rhomboidal  grinding 
surface  presents  two  acute  angles,  one  directed  forAvards  and  out- 
wards, and  the  second  backwards  and  inwards;  and  two  obtuse 
angles,  one  directed  forwards  and  inwards,  and  the  other  back- 
wards and  outwards.  The  side  to  which  each  upper  molar  belongs 
may  easily  be  determined  by  observing  these  angles,  together 
with  the  convexity  of  the  outer  surface,  and  also  by  the  fact  that 
the  anterior  inner  cusp  is  the  largest.  Sometimes  only  three 
cusps  are  observed,  at  others  there  are  five,  and,  in  the  latter 
cases,  the  larger  number  is  found  in  the  outer  row. 

The  upper  molars  have  three  roots.  One  springs  from  the 
inside  of  the  crown  and  is  rounded,  while  the  two  proceeding 
from  the  outside  are  flattened.  The  anterior  external  (facial) 
is  broader  and  longer  than  the  posterior  external  root.  The 
three  diverge,  and  the  inner  or  lingual  root  is  inclined  towards 
the  palate,  while  the  other  two,  situated  one  behind  the  other, 
are  turned  towards  the  outer  wall  of  the  jaw.  Hence,  by  the 
arrangement  of  the  roots  a  right  or  left  upper  molar  may  easily 
be  recognized,  even  Avithout  examining  the  croAvn. 

An  additional  cusp  sometimes  is  met  Avith  upon  the  inner 
Avail  of  the  croAvn,  Avhich,  during  the  eruption  of  the  tooth,  fre- 
quently pierces  the  gum  toward  the  palate,  and  gives  the  ap- 
pearance of  the  emergence  of  a  second  tooth.  The  first  molar 
is  the  largest,  the  third,  or  Avisdom  tooth,  the  smallest.  The 
cusps  of  the  latter  frequently  are  stunted,  and  the  three  roots 
seldom  perfect,  their  development  being  interfered  with  from 
want  of  space.  The  roots  appear,  therefore,  as  if  compressed  to- 
gether, or  are  indicated  merely  by  grooves.  The  roots  incline 
backAvards. 

The  lotver  molars  have  a  rectangular  quadrangular  croAvn 
and  only  two  roots.  The  upper  and  loAver  molars  ma}''  there- 
fore be  distinguished  either  by  their  croAvns  or  roots.  On  the 
upper  surface  of  the  first  molar  are  found  five  cusps,  three  of 
them  in  an  outer  roAv,  tAvo  in  an  inner;   of  the  three  outer,  the 


DESCRIPTION    OF    THE    PERMANENT    TEETH. 


37 


anterior  is  the  largest,  tlie  posterior  the  smallest,  and,  therefore, 
by  this  arrangement  of  the  cusps  the  crown  of  a  right  or  left 
first  molar  can  be  recognized.  On  the  upper  surface  of  the 
second  lower  molar  there  are  only  four  cusps,  separated  from 
each  other  by  a  crucial  depression.  The  wisdom  tooth  frequently 
presents  upon  the  surface  of  its  crown  the  crucial  depression 
with  the  four  cusps,  but  quite  often  they  are  less  distinct,  and 
at  times  merely  indicated  by  the  existence  of  small  rounded 
eminences.  The  outer  or  buccal  are  more  convex  than  the 
inner  or  lingual  surfaces  of  the  crowns. 

The  two  roots  of  each  molar  are  flattened,  grooved,  and  are 
placed  in  front  and  behind  respectively.  The  anterior  root  is 
broader  and  longer  than  the  posterior,  and  in  connection  with 
the  easily  recognized  external  surface  of  the  crown,  serves  to 
distinguish  the  right  and  left  teeth.  The  crowns  and  roots  of 
the  wisdom  teeth  are  frequently  stunted ;  the  roots  are  com- 
monly connate,  curve  backwards  in  the  form  of  a  hook,  and  not 
infrequently  project  into  the  coronoid  process  of  the  lower  jaw. 

Transverse  sections  of  the  jaw,  at  the  distance  of  twelve  to 
fourteen  millimetres  from  the  grinding  surfaces  of  the  teeth, 
afford  an  instructive  vie\^  of  the  size, 
form,  and  position  of  the  separate  roots 
in  relation  to  each  other.  With  the 
exception  of  the  lingual  roots  of  the 
upper  molars  and  the  frequently  cloven 
roots  of  the  first  upper  bicuspids,  they 
have  an  irregular  oblong  form,  are 
broader  on  the  facial  and  narrower  on 
the  lingual  side. 

In  the  upper  jaw  (Fig.  3),  except- 
ing the  lingual  roots  of  the  molars 
and  of  the  first  or  second  bicuspids, 
all  the  roots  are  located  quite  near  to 
the  facial  wall  of  the  jaw,  upon  which  surface  they  are  broader. 


*  Fig.  3.— Transverse  section  of  the  right  half  of  the  superior  maxillary 
arch,  with  the  corresponding  roots  and  root  canals.  This  case  is  exceptional, 
since  the  root  of  the  second  bicuspid  presents  in  this  section  two  apices. 
Natural  size. 


38 


ANATOMY    AND    PHYSIOLOGY. 


The  lingual  roots  of  the  molars  and  bicuspids  are  imbedded  in 
the  cancellated  substance  of  the  bone ;  sections  of  the  central 
incisor  and  the  canine  have  a  rounded  triangular  shape ;  those 
of  the  lateral  incisor  an  oval,  and  those  of  the  first  and  second 
bicuspids,  before  their  final  occasional  division  into  two  apices, 
a  biscuit  [dumb-bell}  shape.  If  the  bicuspids  have  two  deeply- 
notched  roots,  the  buccal  root  is  flattened  and  presents  three 
rounded  angles.  The  buccal  roots  of  the  mo- 
lars are  convex  on  the  facial  side,  and  con- 
siderably narrower  on  the  lingual  side ;  the 
lingual  roots  are  nearly  circular.  In  the  under 
jaw  (Fig.  4)  the  roots  are  arranged  in  a  row, 
one  behind  the  other,  and  are  somewhat  thicker 
on  the  facial  than  on  the  lingual  side,  the  bis- 
cuit shape  predominating.  The  roots  of  the 
incisors,  canines,  and  bicuspids,  and  also  the 
larger  anterior  root  of  the  first  molar,  are  press- 
ed against  the  facial  wall  of  the  jaw ;  the  smaller 
posterior  root  of  the  first  molar  and  the  roots 
of  the  second  and  third  molars  are  placed  in 
the  middle  of  the  jaw,  equidistant  from  the 
facial  and  lingual  wall.  The  conipact  cortical  substance  is  con- 
siderably thicker,  the  cancellated  substance  thinner  than  in  the 
upper  jaw. 

The  thickness  of  the  roots  corresponds  exactly  with  that  of 
the  crown  ;  that  is,  if  the  crowns  are  thicker  upon  one  side,  then 
the  roots  upon  the  corresponding  side  are  also  thicker.  The 
larger  projecting  coronal  cusps  have  thicker  roots  corresponding 
'with  them,  as  was  observed  in  the  case  of  the  anterior  buccal 
roots  of  the  upper  molars.  The  outlines  of  transverse  sections 
of  the  root  canals  correspond  with  those  of  the  roots. 

Temporary  Teeth. — These,  generally  speaking,  closely  re- 
semble the  permanent  teeth.  A  description  of  the  crowns  of  the 
milk  incisors  and  canines  is  unnecessary,  as  the  preceding  ob- 

*  Fm.  4  — Transverse  section  of  the  left  half  of  the  inferior  maxillary 
arch  and   tiie  corresponding  roots   and   root  canals.     The  posterior  root  of       ) 
the  wisdom  tooth   is   abnormally  formed.     It  should  have  a  biscuit  shape. 
Natural  size. 


DESCRIPTION    OF    THE    TEMPORARY    TEETH.  39 

servations  in  reference  to  the  cro-\vns  of  the  permanent  incisors 
and  canines  are  equally  applicable  to  those  of  the  former.  The 
milk  teeth  with  single  roots  can  only  be  distinguished  from  the 
corresponding  permanent  teeth  by  the  generally  roundish  roots 
of  the  former  and  by  their  inclination  in  a  direction  opposite  to 
those  of  the  permanent  teeth. 

The  deciduous  molars  alone  deserve  particular  consideration. 
With  children  these  teeth  take  the  place  of  the  permanent  or 
true  molars,  and  have  the  same  general  form.  The  first  decidu- 
ous molar  resembles  the  permanent  bicuspid  in  form,  while  the 
second  is  an  exact  counterpart  of  a  permanent  molar.  It  is 
hardly  necessary,  therefore,  to  mention  that  the  first  molar  is 
smaller  than  the  second. 

The  first  upper  milk  molar  has  a  broad  crown,  is  flat  upon 
the  anterior  (medial)  and  posterior  (lateral)  surface,  Avhile  the 
external  and  internal  surfaces  are  convex.  Projecting  forward 
from  the  anterior  half  of  the  outer  surface,  near  the  neck  of 
each  tooth,  a  prominence  is  found,  by  means  of  which  also  they 
may  always  be  recognized.  The  grinding  surface  presents  two 
cusps,  separated  by  a  longitudinal  groove,  one  of  which  is  on 
the  outside,  the  other  on  the  inside. 

The  crown  of  the  second  upper  molar  has,  on  a  smaller  scale, 
exactly  the  form  of  the  first  permanent  molar.  All  the  upper 
molars  have  three  roots,  the  position  and  shape  of  which  corres- 
pond exactly  with  those  of  the  upper  permanent  molars,  except 
that  the  former  are  more  divergent  than  the  latter. 

The  loiver  deciduous  molars  have  more  elongated  crowns, 
that  of  the  first  resembling  somewhat  that  of  a  permanent  bi- 
cuspid, while  that  of  the  second  is  very  similar  to  the  crown  of 
the  first  permanent  molar.  The  first  are  characterized  further 
by  a  protuberance  found  on  the  outer  surface  of  the  crown,  and 
by  two  small  depressions  on  the  grinding  surface,  of  which  the 
first  is  the  smaller,  both  being  surrounded  by  elevations  of  en- 
amel. Upon  the  grinding  surface  of  the  second,  the  cusps  are 
more  distinct,  and  frequently  five  in  number,  three  on  the  outside, 
and  two  on  the  inside,  the  anterior  external  one  being  the  largest. 
The  lower  teeth,  like  the  lower  permanent  molars,  have  two  flat- 


40  ANATOMY    AND    PHYSIOLOGY. 

tened  widely  separated  grooved  roots,  each  of  Avhicli  is  formed, 
as  it  were,  by  the  blending  together  of  two  contiguous  roots. 

The  distinctions  between  the  milk  and  jjermanent  teeth  are 
found  principally  in  their  coIo?-,  form,  and  size.  The  milk  teeth 
present,  even  externally,  the  indications  of  a  more  delicate  tex- 
ture. They  have  a  much  whiter,  even  milk-white,  color,  and 
as  the  period  for  their  detachment  approaches,  a  bluish-white 
color.  On  the  other  hand,  permanent  teeth,  particularly  when 
they  first  appear,  are  of  a  yellowish  shade,  which  passes  into  a 
decided  yellow  near  the  gum.  This  difference  is  much  more 
noticeable  if  a  milk  tooth  happens  to  be  next  to  a  lately  cut  per- 
manent tooth.  Milk  teeth,  as  before  stated,  are  also  smaller  in 
all  their  dimensions  as  they  are  placed  in  the  still  undeveloped 
jaws  of  childhood.  Permanent  teeth,  when  first  cut,  have  quite 
as  broad  a  crown  as  in  later  life,  and  therefore  the  difference  in 
size  between  them  and  the  milk  teeth  is  much  more  striking. 
The  cutting  edges  of  the  permanent  incisors,  as  before  stated, 
are  divided  into  three  blunted  denticles  by  two  notches ;  two 
shallow  grooves  also  traverse  the  labial  surfaces  of  these  teeth, 
disappearing  gradually  toward  the  necks ;  these  denticles  and 
grooves  can  be  seen  only  in  young  incisors,  for  they  disappear 
from  attrition  in  the  course  of  a  few  years.  These  are  also 
present  in  young  milk  teeth,  but  as  they  immediately  wear  away, 
their  absence  affords  a  quite  positive  basis  of  distinction  between 
milk  and  young  permanent  teeth.  One  of  the  most  notable  points 
of  distinction  between  the  teeth  of  the  two  sets  is  afforded  by 
the  fact  that  the  milk  teeth,  at  the  period  of  shedding  tiie  teeth, 
are  considerably  worn  away,  Avhile  the  new  teeth  have  very 
sharp  edges  and  eminences.  The  roots  of  the  deciduous  molars 
diverge  considerably,  because  they  include  the  crowns  of  the 
permanent  bicuspids  between  them,  like  a  pair  of  tongs. 

Arrangement  of  the  Permanent  Teeth. — In  their  normal  con- 
dition, the  two  rows  of  teeth  form  two  arches,  lying  one  above 
the  other,  with  their  convexities  directed  forwards  and  their 
concavities  backwards.  When  the  mouth  is  closed  the  bicuspids 
and  molars  of  the  two  rows  are  situated  in  the  same  perpen- 
dicular planes ;  the  upper  incisors  and  canines,  on  the  contrary, 
are  directed  somewhat  obliquely  forwards,  in  a  direction  oppo- 


ARRANGEMENT  OF  THE  PERMANENT  TEETH. 


41 


site  to  that  of  the  corresponding  lower  teeth,  and  project  slightly 
beyond  the  latter.  The  intervals  between  the  upper  and  the 
lower  central  incisors,  and  the  two  frcena  lahiorum  are  in  the 
median  line. 

The  upper  row  of  teeth  forms  a  quite  uniform,  nearly  semi- 
elliptical  arch,  with  its  posterior  extremities  drawn  towards  each 
other,  while  the  lower  teeth  form  a  parabolic  curve,  narrower 
in  front,  the  arms  of  which  diverge  posteriorly.  The  upper  in- 
cisors, as  a  whole,  are  broader  than  the  lower,  and  the  upper 
canines  also  include  a  larger  space  than  the  lower,  consequently 
the  right  anterior  upper  teeth  do  not  stand  directly  over  the 
corresponding  lower  ones,  but  the  central  upper  incisor  covers 


the  whole  of  the  edge  of  the  opposite  central  and  the  medial 
half  of  the  lateral  lower  incisor.  The  upper  lateral  incisor 
covers  the  distal  half  of  the  lower  lateral  incisor  and  the  medial 


*  Fig.  5. — A  well-developed  set  of  permanent  teeth,  projected  upon  a 
plane  in  order  to  show  the  mutual  relations  of  the  upper  and  under  teeth 
and  the  curve  described  by  the  upper  and  under  rows  of  teeth.  Facial  view. 
The  first  five  teeth  in  this  case  project  over  the  under  ones  in  a  decreasing 
proportion,  that  is,  the  first  upper  incisor  projects  the  most,  and  the  second 
upper  bicuspid  the  least ;  each  of  these  five  teeth  also  overlaps  the  tooth  ad- 
jacent to  its  immediate  opponent.  The  size  of  the  crown  of  the  first  lower 
molar  is  such  that  the  crowns  terminate  on  the  same  line.     Natural  size. 


42 


ANATOMY    AND    PUYSIOLOGY. 


half  of  tlic  canine.  The  upper  canine  tooth  is  inserted  between 
the  lower  canine  and  first  bicuspid  ;  the  first  upper  bicuspid  be- 
tween the  first  and  second  loAver  bicuspid.  But  as  the  second 
upper  bicuspid  has  a  narrower  crown  than  the  first,  while  the 
reverse  is  true  of  the  lower  bicuspids,  it  is  found  usually  that 
the  first  upper  molar  stands  directly  over  the  lower,  and  is  in 
relation  with  only  a  slight  portion  of  the  edge  of  the  second 
lower  molar.  Finally,  as  the  upper  wisdom  tooth  is  generally 
smaller  than  the  lower,  it  results  that  the  complete  dental  arches 
are  equal  in  length.     Variations  are  of  frequent  occurrence. 

The  incisive  edges  and  masticatincj  surfaces  of  the  two  rows 
of  teeth  form  serpentine  c^trves  which  correspond  Avith  the  pre- 
viously mentioned  wavy  outlines  of  the  margins  of  the  alveolar 


Fig.  6/ 


processes,  and  are  conformable  to  the  variations  in  the  lengths 
of  the  crowns.  In  the  upper  jaw  this  curve  presents  convexi- 
ties downwards  in  the  middle  of  the  two  lateral  portions,  corres- 
ponding to  concavities  directed  upwards  in  the  lower  jaw,  while 


*  Fig.  6. — A  well-developed  set  of  deciduous  teeth,  together  with  the 
crowns  of  the  permanent  teeth  inclosed  in  their  capsules,  projected  upon  a 
plane.  The  three  anterior  upper  milk  teeth  project  over  the  lower  ones.  The 
upper  canine  overlaps  the  lower  one  somewhat  posteriorly.  As  the  crowns 
of  the  upper  are  smaller  than  those  of  the  lower  molars,  the  second  molars 
terminate  posteriorly  upon  the  same  line.  The  curves  described  by  the  upper 
and  lower  rows  are  evident,  but  are  less  marked  than  in  the  permanent 
set.     Natural  size. 


THE    HARD    TISSUES    OF    THE    TEETH.  43 

tlie  converse  is  true  of  the  relations  presented  by  the  arches  of 
the  anterior  portions  of  the  jaws. 

In  the  further  description  of  the  dental  arches  it  may  be  men- 
tioned that  a  single  sharp  edge  extends  along  the  summits  of 
the  three  front  teeth,  while  upon  the  bicuspids  and  beyond  it  is 
double  and  is  formed  by  the  two  rows  of  cusps.  Between  these 
two  rows  a  shallow  groove  extends  backwards. 

Generally  the  crowns  diminish  in  length  from  before  back- 
wards, so  that  the  incisors  project  the  most,  the  wisdom  teeth 
the  least,  from  their  sockets. 

The  arrangement  of  the  milk  teeth  differs  from  that  of  the 
permanent,  inasmuch  as  the  second  molars  terminate  the  rows 
of  the  former  posteriorly,  and  the  deciduous  molars  generally 
have  larger  crowns  than  the  permanent  bicuspids.  The  three 
upper  front  teeth  project  over  the  lower  to  a  comparatively  less 
degree  (Fig.  6). 

The  Hard  Tissues  of  the  Teeth. — Human  teeth  are  com- 
posed of  three  separate  tissues;  the  dentine  (tooth-bone)  consti- 
tutes the  principal  mass,  while  the  remainder  is  composed  of 
the  enamel,  Avhich  forms  a  covering  for  the  crown,  and  the 
cement,  which  covers  the  root. 

The  dentine,  ivory  or  tooth-bo7ie,  forms  the  pi-incipal  part  of 
the  tooth,  and  o-ives  to  it  its  form,  so  that  the  diflferent  kinds  of 
teeth  may  easily  be  recognized,  even  after  the  separation  of 
the  enamel  and  cement.  Comparative  histology  also  illustrates 
this  fact,  for  in  tracing  back  teeth  of  the  animal  kingdom  to  a 
rudimentary  form  in  the  order  of  their  development,  the  den- 
tine is  found  to  occur  earlier  than  the  enamel  and  cement. 

The  dentine  presents  for  consideration  a  peripheral  or  outer 
surface,  which  is  in  relation  with  the  enamel  and  cement,  and 
an  inner  surface  which  incloses  the  pulp-cavity  or  root  Cijnal, 
and  has  an  organic  connection  with  the  pulp. 

The  elements  which  characterize  the  dentine  are  the  den- 
tinal canals  or  tubes  imbedded  in  the  basis-substance,  which 
ramify  in  various  directions  from  the  inner  surface  toward  the 
periphery.  These  canals  gradually  become  more  narrow  as  they 
approach  the  periphery  and  everywhere  pursue  a  wavy  course. 
In  its  course  the  principal  canal  divides  dichotomously,  at  au 


4-i  ANATOMY    AND    PHYSIOLOGY. 

acute  angle,  into  branches  ^vllich  also  subdivide  at  regular  in- 
tervals. At  uniformly  short  distances  from  the  periphery  of 
the  dentine  the  canals  are  divided  into  numerous  minute 
branches';  but  throughout  the  entire  course  of  the  main  tubes 
and  their  branches  there  occur  also  at  short  intervals  quite 
numerous  twig-like  branches  Avhich  ramify  in  various  direc- 
tions, in  some  cases  forming  transverse  and  oblique  anastomoses 
with  the  neighboring  canals,  in  others,  connecting  with  each 
other  by  means  of  sharply  curved  loops.  According  to  "Welcker* 
the  dental  canals  pursue  a  spiral  course. 

In  order  to  obtain  a  definite  idea  of  the  great  multitude  of 
secondary  branches,  a  thin  section  should  be  placed  in  pure 
Canada  balsam,  or  slightly  macerated  in  very  dilute  hydro- 
chloric acid,  when  the  delicate  tubules,  divided  transversely  and 
obliquely,  will  be  brought  clearly  into  view.  Under  very  high 
magnifying  powers  the  macerated  portions  present  a  foveated 
or  honeycombed  appearance.  The  question  whether  the  fine 
tubules  also  terminate  in  free  extremities  within  the  basis-sub- 
stance is  difficult  to  determine.  It  is  quite  probable,  however, 
that  they  form  an  inclosed  system,  from  the  fact  that  clearly 
defined  anastomoses  are  so  numerous. 

Formerly  the  canals  were  considered  to  be  mere  cavities, 
throufdi  which  circulated  a  fluid  containino;  calcareous  salts 
in  solution,  and  an  analogy  was  drawn  between  them  and  the 
canals  of  bone.  Since,  however,  J.  Tomest  has  shown  that 
each  dentinal  tubule  is  tenanted  by  a  soft  fibre,  this  earlier  im- 
pression must  be  abandoned.;); 


*  Zeitschr.  fiir  rationelle  Med.  N.  F.     Bd.  viii. 

t  Phil.  Trans.,  v.  146. 

J  E.  Neumann  (Beitrage  zur  Konntniss  des  normalen  Zahn-  und  Knochen- 
gowebes)  maintains  tiie  existence  ot  special  calcareous  sheaths  of  the  den- 
tinal fibres.  These  he  calls  dentinal  sheaths,  and  he  asserts  that  they  may 
be  isolated,  while  he  bases  his  opinion  upon  the  ground  that  maceration  or 
incineration  destroys  the  fibres,  and  that  the  felted  mass  of  filaments,  which 
remains  after  the  destruction  of  the  basis-substance  by  means  of  hydro- 
chloric acid,  must  be  regarded  as  the  persisting  sheaths  of  the  fibres.  The 
correctness  of  this  theory  of  the  destruction  of  the  fibres  by  maceration  or 
by  incineration  I  am  inclined  to  doubt,  until  a  distinction  is  established  be- 
tween the  fibres  presented  in  a  non-macerated  specimen  of  dentine  and 
those  which  are  isolated  in  one  which  has  been  subjected  to  the  process  of 


THE    HARD    TISSUES    OF    THE    TEETH.  45 

The  intertubular  or  basis-tissue  of  the  dentine  is  so  generally 
traversed  by  the  dental  canals  that  it  is  difficult  to  make  a  proper 
morphological  analj'sis  of  it.  It  has  the  appearance  of  a  homo- 
geneous substance,  with  a  double  refractive  power,  whi<3h,  after 
the  extraction  of  the  calcareous  salts  by  means  of  hydrochloric 
acid,  furnishes  an  organic  residue  resembling  ossein,  the  so- 
called  dental  cartilage,  which  also  possesses  the  property  of 
double  refraction.  Whether  the  calcareous  salts  are  present  in 
the  dentine  in  a  crystalline  form  is  a  question  upon  wdiich 
hardly  anything  is  determined  as  yet.  If  a  section  of  a  tooth, 
that  of  a  horse  for  example,  be  very  slightly  and  carefully 
treated  with  acids,  fine  markings,  perpendicular  to  the  canals, 
are  brought  into  view  which  may  possibly  imply  such  a  con- 
dition. 

The  f/lobular  masses  or  dentinal  globules  are  composed  of  an 
agglomeration  of  transparent,  resisting,  spherical  bodies  of  vari- 
ous sizes,  which,  particularly  with  very  young  persons,  occur 
upon  the  inner  wall  of  the  dentine;  as  a  rule,  also,  upon  its 
periphery,  and  almost  always,  to  a  greater  or  less  degree,  be- 
tween the  dentinal  laminse,  and,  therefore,  may  be  designated 
as  inner,  outer,  and  intercalary  globular  masses.  Where  several 
dentinal  globules  are  contiguous,  they  inclose  a  jagged  space, 
Czermack' s  interglobular  space,  which  is  filled  with  a  substance, 
visible  to  the  naked  eye  and  called  interglobular  substance. 
The  latter,  with  its  jagged  periphery,  might  be  mistaken  for  a 
bone-corpuscle  ;  on  more  careful  examination,  however,  it  Avill 
always  be  seen  that  the  delicate  ramifications  of  the  bone  canal- 
iculi  are  Avanting. 

The  dentinal  canals  are  not  everywhere  uniformly  arranged, 
but  are  separated  more  or  less  into  larger  or  smaller  groups  by 
a  homogeneous  basis-substance,   or  by  globular   masses.     The 

maceration.  The  view  which  seems  to  me  most  phiusible  is  that  the  den- 
tinal fibres  consist  of  a  cortical,  more  dense,  and  a  central  vitreous  sub- 
stance, which  latter  dries  up  as  soon  as  it  is  exposed  to  the  air,  so  that  the 
dentinal  tubules  become  filled  with  air.  The  familiar  luminous  ring  which, 
in  transverse  sections,  is  seen  to  surround  the  dentinal  canals,  and  upon  the 
theory  of  the  existence  of  an  isolable  sheath,  is  interpreted  as  a  calcareous 
dentinal  sheath,  in  my  opinion,  is  to  be  regarded  as  a  homogeneous  basis-sub- 
stance, whicli  invests  the  dentinal  tubes  like  a  sheath. 


46  ANATOMY    AND    PHYSIOLOGY. 

directions  of  the  canals  are  often  very  plainly  perceived  in  cross 
sections  of  the  necl<,  and  correspond  -with  the  laminated  structure 
of  the  dentine.  The  globular  masses  inserted  between  the 
lamina?  are  often  found  in  great  abundance  in  otherwise  per- 
fectly normal  human  or  animal  teeth,  and  are  then  to  be  con- 
sidered as  evidences  of  interruptions  in  the  regular  process  of 
development.  Under  the  head  of  Pathology  will  be  found  a 
further  consideration  of  the  question,  whether  the  globular  sub- 
stance represents  a  primary  stage  in  the  development  of  the 
dentinal  tissue  (globular  formation),  or  an  osseous  tissue. 

Comparative  history  furnishes  two  other  dentinal  formations 
which  may  be  alluded  to  in  this  connection,  though  their  con- 
sideration is  included  under  the  head  of  Pathology.  They  are 
the  so-called  vaso-dentme  and  osteo-dentine  of  R.  Owen,  de- 
scribed in  his  "  Odontography."  The  first  is  characterized  by 
a  system  of  cylindrical  vascular  canals  which,  like  the  Haver- 
sian canals  of  bone,  traverse  the  dentine  and  are  connected 
with  the  bloodvessels  of  the  pulp.  The  osteo-dentine  is  observed, 
generally,  upon  the  surface  of  the  pulp-cavity  and  seems  to  be 
a  combination  of  irregular  dentine  with  more  or  less  accurately 
defined  osseous  tissue. 

The  enamel  forms  a  hood-like  investment  of  the  coronal  portion 
of  the  dentine,  and  is  composed  of  a  very  hard,  brittle  substance 
Avhich  is  thickest  upon  the  edges  of  the  incisor  teeth,  and  upon 
the  cusps  of  the  others,  is  less  thick  where  it  forms  a  lining  to 
the  coronal  depressions,  and  becomes  gradually  thinner  towards 
the  commencement  of  the  root,  where  it  terminates  abruptly, 
and  is  slightly  overlapped  by  a  rudimentary  layer  of  cement. 

The  outer  exposed  surface  of  the  enamel  is  everywhere 
smooth  normally,  but  the  inner  surface,  on  the  contrary,  which 
unites  with  the  dentine,  presents  everywhere  slight  irregularities. 
Upon  the  external  surface,  particularly  in  the  teeth  of  young 
persons,  and  most  plainly  upon  the  labial  surfaces  of  the  front 
teeth,  delicate  ridges  may  be  seen  with  a  lens,  running  trans- 
versely, and  separated  from  each  other  by  tolerably  equal 
intervals.  ^ 

In  the  teeth  of  older  people,  or  in  those  where  the  enamel  is 
not  regularly  developed,  these  lines  or  ridges  are  less  distinctly 


THE    HARD    TISSUES    OF    THE    TEETH.  47 

or  only  partially  visible,  and  sometimes  are  entirely  impercepti- 
ble;  the  lingual  surfaces  of  the  enamel  have,  usually,  the  more 
polished  appearance.  In  order  to  examine  the  dentinal  surface, 
it  is  best,  as  recommended  by  Giebel,  to  corrode  the  dentine  by 
a  boiling  fifty  per  cent,  solution  of  sulphuric  acid,  b}^  which 
means  the  enamel  cap  may  be  detached.  If  now  the  inner  sur- 
face of  the  dried  cap  be  examined  under  a  sufficiently  high 
magnifying  power  and  with  reflected  light,  a  series  of  diminu- 
tive rounded  elevations  will  be  perceived. 

The  thickness  of  the  enamel  varies  in  the  different  kinds  of 
teeth.  On  the  front  ones,  it  is  somewhat  thicker  on  the  labial 
than  on  the  lingual  surface,  measuring  on  the  incisors  nearly 
one  millimetre,  and  on  the  canines  somewhat  more  ;  on  the  bi- 
cuspids and  molars  the  enamel  is  thicker  than  on  the  front  teeth, 
and  is  thickest  on  the  first  molars.  It  attains  its  greatest  thick- 
ness at  the  summits  of  the  cusps,  where  it  measures  two,  some- 
times even  three  millimetres.  The  thinning  of  the  enamel 
towards  the  roots  is  quite  gradual  on  the  front  teeth,  while  on 
the  back  ones  it  terminates  somewhat  more  abruptl}^  and  pre- 
sents a  proportionately  rapid  increase  in  thickness. 

The  elementary  organs  of  the  enamel  are  calcified,  cylindrical 
cells,  blended  together  in  their  long  diameters,  so  as  to  present 
the  appearance  of  striated  fibres — the  so-caWed  enamel  fibres ; 
in  transverse  sections,  they  present  a  polygonal  appearance,  on 
account  of  their  being  packed  closely  together,  but  occasionally 
are  more  or  less  rounded.  These  longitudinal  chains  of  calcified 
cells  are  united  into  bundles  which  pursue  a  wavy  course  and 
decussate  one  with  another.  Therefore,  in  longitudinal  and 
transverse  sections  of  the  enamel  cap,  longitudinal,  transverse, 
and  oblique  sections  of  the  enamel  cylinders  (enamel  pi-isms)  are 
met  with. 

Isolation  of  the  enamel  fibres  may  easily  be  effected  by  means 
of  dilute  hydrochloric  acid.  The  fibres  becoming  swollen  and 
varicous,  present  on  the  depressed  portions  an  apparent  trans- 
verse striation,  and  between  the  opposing  contiguous  portions, 
narrow  fissure-like  intervals  remain  Avhich  have  given  rise  to  the 
view  entertained  by  some  investigators  that  canals  are  found  in 
the  enamel.     The  appearances  presented  by  a  section  in  which 


48  ANATOMY    AND    PHYSIOLOGY. 

the  fibres  pursue  a  longitudinal  course  are  particularly  deceptive ; 
but  with  careful  examination  these  intervals  cannot  be  con- 
founded with  canals,  for  it  will  be  seen  that  they  have  no  branches 
and  cannot  be  isolated.  The  intervening  substance  between  the 
enamel  fibres  is  transparent  normally,  but,  in  frequent  anoma- 
lous conditions  it  presents,  in  many  places,  a  foraminated,  indis- 
tinctly granular  appearance. 

The  calcareous  salts  are  deposited  in  the  enamel  fibres  in  a 
crystalline  form.  If  a  very  thin  section  of  enamel  be  treated 
Avith  largely  diluted  hydrochloric  acid,  the  edge  Avill  be  seen  to 
become  uniformly  indented,  and,  as  the  action  of  the  acid  con- 
tinues, a  precipitation  of  acicular  crystals  ensues,  which  imme- 
diately redis^lve.  If  cross  sections  of  the  enamel  fibres  are 
carefully  examined  after  a  slight  action  of  the  acid,  they  will 
appear  to  be  filled  with  angular  grains,  which  also  are  the 
needle  crystals  of  phosphate  of  lime  in  transverse  sections. 

It  is  difficult  to  generalize  the  direction  and  grouping  of  the 
eyiamel  fibres.  They  vary  in  difi"erent  kinds  of  teeth  and  diff"er 
in  the  same  tooth  in  accordance  with  the  varieties  in  its  forma- 
tion. The  fibres  are  of  unequal  length  and  thickness,  and  are 
collected  together  into  bundles  which  decussate  with  each  other 
so  as  to  present  in  many  places  a  felted  mass.  If  sections  in 
the  longitudinal  axes  of  the  crowns  of  the  incisors  are  examined, 
it  will  be  seen  that  entire  bundles  which  have  fallen  within  the 
section  are  separated  from  each  other  by  uniform  intervals, 
while  the  latter  are  occupied  by  those  which  are  cut  across 
transversely  and  obliquely.  A  similar  relation,  in  respect  of 
arrangement,  prevails  throughout  the  entire  enamel,  and  is  more 
distinctly  displayed  in  sections  corresponding  with  the  longi- 
tudinal axes  of  the  coronal  cusps  of  the  bicuspids  and  molars. 
The  fibres  of  the  latter,  however,  in  those  portions  where  the 
enamel  becomes  thinner,  not  infrequently  assume  a  parallel  di- 
rection. The  decussation  of  the  bundles  also  aff"ords  an  expla- 
nation of  an  optical  phenomenon  which  is  presented  when  such 
a  longitudinal  section  of  enamel  is  examined  under  the  lens  by 
means  of  very  oblique  reflected  light,  and  with  a  dark  back- 
ground. Under  such  circumstances  the  transversely  divided 
bundles  are  presented  in  the  form  of  luminous  striiv,  while  those 


THE    HARD    TISSUES    OF    THE    TEETH.  49 

which  are  seen  in  their  long  diameters  have  an  opaque  appear- 
ance. The  converse  view  is  obtained  with  transmitted  lio-ht. 
If  we  examine  an  entire  set  of  teeth,  it  will  he  found  that  de- 
cussations of  the  bundles  are  most  marked  in  portions  corres- 
ponding to  the  papillary  projections,  a  fact  readily  understood 
when  it  is  considered  that  the  directions  taken  by  the  formative 
enamel  cells  in  their  growth  vary  the  most  in  localities  Avhere 
the  greatest  curvatures  occur. 

Transverse  sections  of  enamel  present  a  series  of  striations 
which  follow  concentrically  the  contour  of  the  dentine.  They 
are  curved  like  a  bow,  are  sharply  defined,  nearly  equidistant 
from  each  other,  and  may  be  regarded  as  probably  only  an  ex- 
pression of  the  laminated  mode  of  formation  of  the  enamel. 

The  enamel  of  the  teeth  of  young  persons  is  transparent  in 
thin  layers,  and  of  a  yellowish  color.  The  color,  however, 
presents  numerous  varieties  which  bear  a  certain  relation  to 
the  durability  and  hardness.  As  a  rule,  it  may  be  said  that 
yellowish  enamel  is  the  most  durable ;  its  fibres  also  are  more 
uniformly  disposed.  In  this  connection  it  would  be  well  to  as- 
certain whether  the  organic  matters  are  not  more  abundant  in 
the  latter  enamel  than  in  other  forms.  A  very  durable  en- 
amel, has  a  uniformly  dense,  resisting  texture,  a  smooth  surface, 
offers  considerable  resistance  to  the  action  of  a  file,  and  has  a 
certain  degree  of  transparency.  The  enamel  of  whiter  teeth 
generally  is  of  more  moderate  strength,  breaks  more  easily,  and 
contains  perhaps  less  organic  substance.  In  teeth  of  chalky 
whiteness,  it  is  often  thicker  and  crumbles  easily.  In  such  cases 
the  enamel  contains  an  opaque  granular  mass  which  renders  the 
recognition  of  its  fibres  impossible.  Bluish-white  teeth  are  the 
most  delicate,  and  have  a  thin  layer  of  enamel.  Less  durable 
enamel  is  of  an  irregular,  less  compact  texture,  which  offers  less 
resistance  to  the  file,  and  with  transmitted  light  thin  sections 
of  it  are  often  clouded  by  dark  spots,  which  appear  Avhite  with 
reflected  light. 

Enamel  frequently  contains  light  or  dark  brown  deposits  of 
pigment.  In  the  teeth  of  animals,  this  brown  discoloration  is 
observed  sometimes  towards  the  periphery  of  the  enamel,  at 
other  times  internally,  near  the  dentine,  and  even  the  fibres  are 

4 


50 


ANATOMY    AND    PUYSIOLOGY. 


Fig.  7.t 


impregnated  with  the  coloring  niiitter.  Tiie  enamel  of  human 
teeth,  alsoy  contains  light  and  dark  brown  pigment  without  the 
least  trace  of  cohesion  of  tlie  particles.  The  dark  pigment  is 
found  also  in  the  limiting  or  cortical  substance  of  each  enamel 
fibre,  in  consequence  of  which  a  transverse  section  of  the  latter 
presents  the  appearance  of  a  circle  of  pigment.  This  cortical 
pigmentary  deposit  in  the  enamel  fibres  not  infrequently  reaches 
only  to  a  certain  depth  in  the  layer  of  each  fibre,  and  to  this 
circumstance  is  to  be  ascribed  the  fact  that  the  concentric  stri^ 
are  more  distinct  in  enamel  containing  pigment. 

Enamel,  as  is  well  known,  has  a  property  of  double  refraction, 
which  has  recently  been  investigated  by  Hoppe-Seyler.*  When 
fully  developed,  it  exhibits  negative  double  refraction,  and 
positive  while  its  development  is  in  progress.  By  heating  to 
800°,  the  negative  refraction  becomes  positive.  Cross-sections 
of  the  prisms  present  no  double  refractive  power. 

The  junction  of  the  enamel  with  the  dentine  is  effected  by 

a    transparent,    irregularly    wavy, 
boundary    layer    which,    in    some 
parts,  is  encroached  upon  by  sep- 
arate dentinal  canals  (Fig.  7),  and 
in   others   by   elongated  cleft-like 
cavities,    of   irregular   shapes   and 
different    dimensions.     Into    these 
cavities,    which    are    mostly    filled 
with  opaque,  amorphous  calcareous 
masses,  one  or  another  of  the  den- 
tinal canals  frequently  enters. 
Sometimes,  though  quite  rarely,  a  terminal  loop  is  seen  in  the 
hyaline  boundary  layer.     These  cavities  penetrate  more  or  less 
deeply  into  the  enamel,  and  are  found  most  commonly  in  parts 
corresponding  to  the  incisive  and  masticating  portions  of  the 

*  Virchow's  Archiv,  Bd.  24. 

f  Fig.  7  shows  the  line  of  junction  between  the  dentine  and  enamel  in  a 
longitudinal  section  of  an  incisor.  The  enamel  fibres  are  divided,  partly  in 
their  longitudinal  axes  {a),  and  partly  in  a  transverse  direction  [b).  The 
boundary  layer  is  irregularly  wavy.  The  dentinal  canals  {c)  present  very 
delicate  branches,  which  ramify  toward  the  bordering  layer.  3lagnified 
500  diameters. 


CEMENT.  51 

crown.  Usually  they  run  obliquely  to  the  direction  of  the 
enamel  fibres.  They  seem  to  occur  more  frequently  in  the 
teeth  of  elderly  people,  in  which  the  crowns  have  been  worn 
away  partially  by  attrition. 

If  we  take  into  consideration  these  circumstances,  viz.,  the 
encroachment  of  the  dentinal  canals  upon  these  bounding  layers, 
the  occurrence  of  oblong  cavities  inclosing  dentinal  canals,  the 
penetration  of  these  cavities  only  to  a  certain  depth  into  the 
enamel,  and  their  more  frequent  occurrence  in  old  age,  I  think 
there  is  ground  for  considering  this  bounding  layer,  which  be- 
comes more  evident  in  the  teeth  of  larger  mammals,  as  belonging 
to  the  dentine,  and  therefore  for  regarding  the  cavities  as  results 
of  resorption  of  the  dentine  rather  than  of  defects  in  the  devel- 
opment of  the  enamel.     If  the  crown  of  a  tooth  be  subjected  to 
the  action  of  very  dilute  hydrochloric  acid  for  about  twenty-four 
hours,  the  delicate  membrane,  first  observed  by  Nasmyth  (iVas- 
mytlis  memhrcme),  will  be  detached.     It  may,  however,  even 
without  the  employment  of  acid,  be  demonstrated  by  suitable 
sections  of  the  enamel,  as  a  transparent  layer  with  a  sharply 
defined  exterior.      The  detached  membrane  is  smooth  upon  its 
exposed  surface ;  upon  the  internal  surface,  it  is  connected  with 
the  enamel  fibres,  between  the  rows  of  which  it  sends  processes, 
and  hence  it  presents,  in  many  places,  an  impression  as  it  were 
of  the  contiguous  portions  of  the  rows  of  enamel  prisms.     In 
the  disposition  of  the  pigment  in  the  periphery  of  the  enamel, 
these  impressions   become   still   more   distinct.     Kblliker,  who 
designated  the  membrane  the   "cuticle  of  the  enamel,"  found 
that  it  remained  unchanged  in  boiling  Avater  and  mineral  acids. 
Waldeyer  states  that,  when  boiled  with  caustic  potash  or  soda, 
it  becomes  softened ;  and  when  burned,  it  yields  an  odor  resem- 
bling that  of  burnt  horn.      He  was  unable  to  detect  any  lime 
in  it. 

Cement. — This  forms  an  osseous  covering,  shaped  like  a 
sugar-loaf,  of  the  root  portion  of  the  dentine.  It  is  thickest  at 
the  apex  and'  gradually  becomes  thinner  towards  the  so-called 
neck  of  the  tooth.  At  the  apex  of  each  root  it  is  reflected 
toward  the  internal  surface  of  the  canal  of  the  root,  upon  the 
outermost  portion  of  which  it  is  disposed. 


52  ANATOMV    AND    PHYSIOLOGY. 

The  external  surface  of  the  cement,  in  many  young  teeth 
which  perhaps  are  quite  normal,  presents  delicate  transverse 
striations,  which,  to  the  naked  eye,  resemble  the  striations  which 
may  be  seen  upon  the  surface  of  the  enamel.  In  other  normal 
teeth,  this  surface  is  more  polished  or  marked  by  very  slight 
elevations  and  depressions  which  become  more  decided  near  the 
extremities  of  the  roots. 

Sections  of  normal  cement,  in  which  the  outer  surface  is  pre- 
served intact,  show  that  a  mass  of  minute  nodules,  which  may 
be  termed  the  external  calcareous-granular  layer,  forms  the 
outermost  stratum,  directly  beneath  which  appear  the  bone-cor- 
puscles. This  layer  has  an  organic  connection  with  the  perios- 
teum of  the  root  or  root  membrane,  and,  as  the  development  of 
the  cement  proceeds  from  the  latter,  this  layer  is  to  be  regarded 
as  representing  the  primary  stage  in  the  formation  of  the  cement, 
analogous  to  the  layer  of  dentinal  globules  on  the  inner  surface 
of  young  dentine. 

In  the  thicker  portions  of  the  cement  the  bone-corpuscles  are 
disposed  in  numerous  layers,  one  over  another,  which  subse- 
quently pass  into  a  single  row,  and  finally  disappear  altogether. 
Tiicy  differ  from  true  bone- corpuscles,  inasmuch  as  they  are 
generally  somewhat  larger,  present  a  greater  number  of  radia- 
tions, and  a  greater  diversity  of  form  and  arrangement.  The 
very  numerous  canaliculi  given  off  from  them  immediately 
divide  into  branches  at  very  acute  angles,  the  two  together  pre- 
senting a  tuft-like  appearance.  Sometimes  the  canaliculi 
radiate  from  the  bone-corpuscles  in  parallel  rows,  and  extend  a 
considerable  distance  without  forming  a  network.  The  form  of 
these  bone-corpuscles  varies,  being  spindle-shaped,  rounded, 
triangular  or  polygonal,  pyriform,  &c.  Their  arrangement 
also  varies,  the  long  axes  of  the  elongated  ones  being  parallel 
with  sometimes,  and  at  others  perpendicular  to  that  of  the  root 
of  the  tooth.  Some  are  met  with  closely  packed,  one  upon 
another,  as  it  were  blended  together,  and  others  which  are  far 
apart,  and  between  the  latter  a  considerable  amount  of  inter- 
corpuscular  substance  is  inserted,  which  sometimes  occupies  the 
entire  field  of  view.  This  latter,  particularly  in  the  cement  of 
old  teeth,  presents  a  finely  lamellated  structure,  which  may  be 


JUNCTION  OF  THE  DENTINE  AND  CEMENT.       53 

demonstrated  by  means  of  very  dilute  hydrochloric  acid,  or,  still 
better,  lactic  acid.  The  thickness  of  the  lamellse.  in  portions 
adapted  for  observing  them,  is  so  slight  as  to  be  immeasurable, 
when  viewed  by  ordinary  methods,  and  they  resemble  the 
regular  lamellation  presented  by  the  agate.  In  other  parts  the 
basis-substance  is  generally  diffused,  molecular  or  vitreous, 
homogeneous. 

At  the  periphery  of  the  teeth  of  old  people,  in  which  the 
cement  everywhere,  but  especially  near  the  apices  of  the  roots, 
is  thicker  than  in  those  of  younger  persons,  bone-corpuscles  are 
met  with  not  infrequently,  one,  two,  or  more  of  which  are  in- 
vested by  a  clear,  highly  refractive  layer.  The  radiation  of  the 
canaliculi  takes  place  Avithin  this  bounding  layer,  Avhich  presents 
a  lobulated  appearance  when  it  incloses  several  corpuscles. 
This  condition  of  the  osseous  substance  evidently  corresponds 
with  a  developmental  stage,  an  interstitial  growth,  in  which  the 
resorption  of  the  envelope  of  the  bone-corpuscles  has  not  yet 
taken  place.  Vascular  canals  frequently  occur  in  the  cement 
of  old  teeth,  and  at  the  extremities  of  the  roots  of  younger  teeth, 
also,  one  or  another  may  be  found  extending  from  the  surface 
of  the  cement  through  the  dentine  to  the  root  canal. 

If  the  cement  be  traced  upwards  towards  the  crown  of  the 
tooth,  its  transition  into  a  mere  rudimentary  osseous  substance 
may  be  observed.  The  separate  rows  of  bone-corpuscles  disap- 
pear and  are  succeeded  by  minute  irregular  cavities.  The  most 
striated  portion  of  the  basis-substance  of  the  osseous  tissue  con- 
tinues its  course  alone,  and,  decreasing  in  thickness  toward  the 
attenuated  border  of  the  enamel,  it  projects  over  the  latter  for 
a  short  distance.  At  this  part,  therefore,  the  hard  tissues  of 
the  teeth,  cement,  enamel,  and  dentine,  are  joined  together. 

The  dentine  and  cement  are  connected  together  by  means  of 
a  layer  composed  of  an  agglomeration  of  transparent  globules, 
and  of  varying  degrees  of  thickness..  The  spaces  intervening 
between  the  latter  (interglobular  spaces)  are  irregularly  notched 
and  frequently  in  very  close  proximity  to  one  another ;  they 
are  filled  with  an  opaque,  granular,  calcareous  substance,  and 
very  often  are  in  direct  connection,  on  one  side  with  dentinal 
canals,  and  on  the  other  side  with  the  bone-corpuscles  of  the 


54:  ANATOMY    ANP    PHYSIOLOGY. 

cement.  Sometimes  this  intermediate  layer  is  very  finely 
granular,  and  the  spaces  between  the  grains  are  exceedingly 
small.  The  cement  proper  commences  outside  of  this  layer, 
and  its  canaliculi  rarely  come  into  direct  connection  Avith  th'fe 
dentinal  canals. 

The  Dental  Pulp  occupies  the  cavity  of  the  crown  and  the 
canal  of  the  roots  of  each  tooth,  and  is  the  persisting  germinal 
bed  of  the  dentine,  its  organ  of  nourishment  and  sensation. 
Its  exterior  corresponds  with  that  of  the  tooth,  so  that  if  it  be 
isolated  completely,  its  appearance  alone  will  indicate  to  which 
kind  of  tooth  it  belongs. 

The  pulp  is  divided  into  the  crown  and  radical  portion.  The 
former  is  provided  with  one,  two,  or  more  conical  processes, 
which  correspond  Avith  the  tubercles  upon  the  summit  of  the 
crown,  and  divides  into  as  many  radical  portions  as  there  are 
roots.  The  lengths  of  the  conical  processes  of  the  pulp  bear  a 
direct  relation  to  the  height  of  the  coronal  cusps,  and  hence  in 
the  pulps  of  the  incisors  they  are  barely  discernible  as  three, 
pointed  elevations.  The  thickness  of  the  pulp  also  corresponds 
with  the  exterior  of  the  tooth,  that  is,  the  relatively  thickest 
coronal  portions  are  found  in  the  canine  and  molar  teeth  ;  the 
radical  portions  are  flattened  within  the  compressed  roots. 
With  young  persons  the  pulps  are  thicker  than  with  the  aged, 
and  they  decrease  in  thickness  as  age  advances.  The  pulp  is 
smooth  upon  its  surface,  of  a  yellowish,  reddish-yellow,  or  even 
deep  blood-red  color,  corresponding  with  the  blood  which  it  con- 
tains ;  its  transparency  is  such  that  the  course  of  the  vessels  is 
distinctly  perceptible  at  the  margins ;  its  consistency  is  almost 
like  that  of  young,  succulent  connective  tissue ;  its  connection 
with  the  dentine,  particularly  in  young  teeth,  is  formed  by  a 
delicate,  lax  tissue.  The  outer  surface  of  the  pulp  is  covered 
with  conical  cells,  the  dentinal  cells  [odontoblasts),  from  the 
broad  faces  of  which,  directed  outwards,  comparatively  thick 
processes  extend.  Boll*  observed  several  processes  extending 
from  a  single  cell  towards  the  dentine,  and  also  short  lateral 
ones  which  connected  adjacent  cells. 

*  Archiv  fur  mikr.  Anat.,  iv. 


DENTAL    PULP. 


55 


The  dentinal  processes  enter  the  contiguous  dentinal  canals, 
and,  like  the  latter,  divide  into  branches 
and  numerous  ramifications.  The  pro- 
toplasm of  the  cells  is  finely  granular, 
and  the  nuclei  are  oval.  A  more  slender 
process,  which  occasionally  divides,  ex- 
tends internally  from  these  cells  and  dis- 
appears in  the  connective  tissue,  or  is 
united  with  a  spindle-shaped  nucleated 
cell,  which  latter  indeed  is  to  be  regarded 
as  a  formative  cell,  cell  of  repair  (Ersatz- 
zelle)  (Fig.  8). 

The  basis-tissue  of  the  pulp  consists  of 
a  loose  connective  tissue  containing  scattered  connective-tissue 
cells  of  various  forms,  among  which  the  spindle  shape  predomi- 
nates. Bundles  of  wavy  connective  tissue  serve  to  give  it  firm- 
ness, while  it  is  totally  destitute  of  the  elastic  element.  In  aged 
persons  the  pulp  is  more  dense  and  tenacious,  and  contains,  also, 
a  larger  quantity  of  fibrillated  connective  tissue. 

The  bloodvessels  are  very  abundant ;  several  main  trunks 
enter  and  leave  the  pulp,  and  in  the  root  portion,  partly  also 
in  the  crown,  pursue  a  straight  course  for  the  most  part. 
Transverse  sections  of  the  pulp  give  a  good  idea  of  the  multi- 
tude of  the  vessels  and  their  respective  distances  from  each  other 
(Fig.  9).  The  wider  vessels  are  found  internally,  where  their 
ramifications  present  a  bushy  appearance.  The  sharply-curved 
terminal  loops  of  the  capillaries  are  found  everywhere  beneath 
the  layer  of  dentinal  cells,  and  are  grouped  in  a  manner  simi- 
lar to  that  presented  by  the  ramifications  of  the  vessels  in  the 


*  Fig.  8. — Transverse  section  of  the  marginal  portion  of  the  pulp  from 
the  tooth  of  a  colt.  The  dentinal  cells,  arranged  side  by  side,  present,  at 
their  peripheral  extremities,  free,  elongated,  thick  processes,  which  have 
been  isolated  from  the  dentine;  the  former  contain  within  their  finely 
granular  protoplasm  one  or  two  oval  nuclei,  in  close  proximity  or  at  a  dis- 
tance from  each  other,  present  a  sort  of  annular  constriction  and,  internally 
at  their  pointed  extremities,  are  in  relation  with  the  connective-tissue  cor- 
puscles of  the  parenchyma.  The  cavities  of  numerous  bloodvessels,  divided 
transversely  and  obliquely,  appear  in  the  section.    Magnified  400  diameters. 


56  ANATOMY    AND    PUYSIOLOGY. 

papilkie  of   the  tongue.     Lymphatic  vessels    have    never    been 
demonstrated  in  the  pulp. 

The  nerves  of  the  pulp   are  extremely  numerous,   and  are 
united  into  several  bundles,  the  latter  forming  a  network   of 
ramifications  in    the    body    of   the    pulp. 
They  extend  in  the  neighborhood  of  blood- 
vessels, and  the  manner  of  their  disposi- 
tion  m;iy  be   demonstrated   by  cross-sec- 
y     tions  of  the  body  of   the   pulp  (Fig.  9). 
j=     The  primitive  nerve-tubes  are  quite  small 
J     in  diameter.    We  are  enabled  through  the 
3     researches  of  Czermak  and  H.  Miiller  to 
—  \     recognize  portions  of  the  latter;  but  the 

:;^"  ^     delineation  of  the  exact  mode  of  their  ter- 

mination is   attended  with  extreme   diffi- 
culty.  Bollf  observed  the  transition  of  me- 
,  "  .-^     dullated  (markhalticr)  into  numerous  non- 

'  ' .     "*      ■"'^W     medullated    (marklos)  nerve-tubes,   which 
latter  also  gave  off  very  delicate  branches 
between  the  dentinal  cells.     Whether  these  actually  enter  the 
dentinal  canals  remains  undecided. | 

*  Fig.  9  — Transverse  section  of  the  pulp  of  a  canine  tooth  ;  (a)  row  of  den- 
tinal cells  with  their  isolated,  elongated  processes;  {h)  numerous  bundles  of 
nerve-tubes  and  (c)  capillaries  divided  transversely.  The  cavities  of  the 
vessels  increase  in  diameter  towards  the  central  portion  of  the  pulp  {d).  A 
network  of  connective-tissue  bundles  forms  the  stroma.  Magnified  400 
diameters. 

f  Loc.  cit. 

%  We  know,  from  the  clinical  observations  of  J.  Tomes,  that  the  outer 
surface  of  the  dentine  is  remarkably  sensitive  to  the  action  of  mechanical 
and  chemical  agents,  and  that  the  same  is  true  of  the  inner  portions,  though 
to  a  less  degree.  As  soon  as  the  pulp  is  destroyed,  the  sensibility  of  the 
dentine  ceases.  J.  Tomes  concludes  from  this  fact  that  the  sensitiveness  of 
the  dentine  depends  upon  its  connection  with  the  pulp,  and  that  its  proper 
hard  tissue  possesses  no  inherent  sensitive  properties.  He  is  of  the  opinion 
that  the  sensitive  properties  of  the  dentine  are  due  to  the  solid  dentinal 
fibres  which  formerly  were  thought  to  be  tubes,  and  it  seems  to  him  bj-  no 
means  necessary  to  assume  that  these  fibres  are  actual  nerves.  He  has  suc- 
ceeded no  better  than  others  in  proving  a  connection  between  dentinal  and 
nerve-fibres.  The  anatomical  reasons  fur  the  sensitiveness  of  the  dentine 
remains,  therefore,  a  postulate. 


GUM.  57 

The  Gum  is  that  portion  of  the  raucous  membrane  of  the 
mouth  which  surrounds  the  alveohir  margins  of  the  jaw.  It  is 
closely  adherent  to  the  necks  of  the  teeth  and  is  distinguished 
by  several  peculiarities.  It  is  divided  into  a  labial  (external) 
and  lingual  (internal)  portion,  and  the  curved  laminee  which 
arch  transversely  in  the  intervals  between  the  teeth.  It  is  of  a 
pale  flesh  color,  attenuated,  has  a  glittering  appearance  and  a 
compact  structure.  Two  layers  of  the  gum  require  particular 
consideration,  viz  ,  the  papillary  portion  with  the  epithelium, 
and  the  submucous  connective  tissue.  The  latter  is  intimately 
connected  on  the  one  hand  with  the  periosteum  of  the  bone,  and 
on  the  other  with  the  root  membrane  (periosteum  of  the  root). 
The  papilla',  situated  upon  its  surface,  are  finger-shaped  pro- 
longations of  the  corium  of  the  mucous  membrane,  which  are 
arranged  in  rows.  In  different  portions,  and  in  different  in- 
dividuals presenting  apparently  normal  gums,  many  variations 
occur  in  respect  of  the  size  and  manner  of  grouping  of  the 
papillie.  For  example,  in  somewhat  swollen  gums  particularly, 
groups  of  several  papillae  may  be  seen  arising  from  a  common 
base,  or  a  main  stem  may  divide  into  secondary  ones  from  which 
corresponding  papillary  groups  arise.  The  structure  of  these 
papillae  can  be  demonstrated  properly  only  after  the  removal  of 
the  epithelium.  The  outer  homogeneous  layer  of  connective 
tissue  (lining  [basement]  membrane),  under  very  high  magnify- 
ing powers,  presents  minute  indentations,  which  serve  for  the 
reception  of  the  analogues  of  the  aculeated  or  furrowed  cells  of 
the  Malpighian  layer.  In  the  body  of  the  papilla  lie  fusiform, 
sometimes  rounded,  connective-tissue  corpuscles  situated  at 
regular  intervals,  the  long  axes  of  the  spindle-shaped  ones  cor- 
responding with  the  curve  of  the  papilla,  while  in  the  lower 
part  of  a  papilla  the  direction  of  their  long  axes  becomes  more 
horizontal.  In  the  very  firm  submucous  connective  tissue  of 
the  gum,  delicate  elastic  fibrils  also  are  found,  while  they  are 
wanting,  as  a  rule,  in  the  papillary  portion. 

The  bloodvessels  are  very  numerous,  and  the  relatively  large 
arterial  and  venous  trunks  pursue  a  more  or  less  horizontal 
course  at  the  base  of  the  papillary  portion,  where  the  aflierent 
and  efferent  branches  are  given  off  towards  the  papillte.     The 


58 


ANATOMY    AND    PHYSIOLOGY. 


Fig.  10.* 


final  division  of  tlic  brandies  takes  place,  generally,  at  the 
angle  of  junction  of  two  papillre  (Fig.  10).  Each  papilla  con- 
tains but  one  anastomotic  loop 
which  pursues  an  undulatory 
course.  In  elongated,  pointed 
papillae,  the  direction  of  the  as- 
cending canals  is  more  nearly 
in  a  straight  line. 

The  nerve-fibres  are  thick, 
and  form  a  horizontally  dis- 
posed network  of  ramifications; 
from  these,  separate  nerve-tubes 
extend  nearly  at  right  angles 
toward  the  base  of  the  papillae 
and,  gradually  diminishing  to  delicate  filaments  (axis-cylinders), 
finally  disappear  altogether  from  view  (Fig.  10). 

The  thick  epithelium  is  composed  of  several  layers  of  flat 
cells,  with  oval  nuclei.  Those  of  the  deeper  or  mucous  layer 
present  upon  their  borders  delicate  dotted  markings,  an  appear- 
ance produced  by  a  row  of  aculeated  projections  from  the  lateral 
margins  of  the  cells  ;  these  unite  with  similar  ones  of  neighbor- 
ing cells,  forming  a  sort  of  suture  (Atlas,  Fig.  135). 

There  are  no  glands  belonging  properly  to  the  gums,  though 
sometimes  acinose  glands  are  found  upon  the  lingual  portion 
close  to  its  margin.  With  children  the  gums  frequently  inclose 
rosette-shaped  aggregations  of  epithelial  cells,  appearing,  at 
times,  to  the  naked  eye  like  small  nodules,  which  probably  are 
merely  the  remains  of  the  lateral  convolutions  of  the  enamel 
germ. 

The  Root-Membrane  or  Periosteum  of  the  Root  is  a 
delicate  connective-tissue  membrane  containing  an  abundance 
of  vessels  andVierves;   it  is  intimately  connected  with  the  sub- 


*  Fig.  10  shows  three  papillaj  from  the  gum  of  a  nibbit,  with  the  epithe- 
lium removed,  treated  with  chloride  of  gold  and  acetic  acid.  Each  papilla 
contains  a  vascular  loop.  Rounded  and  spindle-shaped  connectivc-ti.ssue 
cells  are  scattered  throughout  the  tissue.  From  the  nerve-lube  (a)  an  axis- 
cylinder,  which  gradually  becomes  smaller,  is  given  off  at  a  right  angle, 
and  extends  up  to  the  base  of  a  papilla.     Magnified  400  diameters. 


ROOT-MEMBRANE — PERIOSTEUM    OF    THE    ROOT.         59 

mucous  la^^er  of  the  gum  and  with  the  periosteum  of  the  alveolar 
process,  and  covers  the  root  of  the  corresponding  tooth.  It  is 
of  unequal  thickness,  being  somewhat  thicker  near  the  gum  and 
at  the  apex  of  the  root  than  in  the  intermediate  portions.  In- 
dividuals, too,  present  varieties  in  regard  to  its  thickness  ;  for 
instance,  well-preserved  grooved  teeth  have  a  comparatively 
thicker  root-membrane. 

Generally  it  is  of  moderate  density  ;  the  bundles  of  connec- 
tive tissue  forming  it  contain  no  elastic  fibres,  and  inclose  fusi- 
form connective-tissue  corpuscles;  in  addition  to  these,  roundish 
elementary  organs  are  met  with.  According  to  E,  Magitot,* 
the  root-membrane  consists  of  two  portions  :  an  inner,  Avhich 
does  not  admit  of  being  teased  into  fibrils;  and  an  outer,  lying 
near  the  alveolar  Avail,  which  has  the  appearance  of  a  fibrous 
structure.  The  same  writer  also  mentions  the  occurrence  of 
"'  cellules  myeloplaxes,"  similar  to  those  found  in  the  periosteum 
of  bone,  and  cytoblastions  (nuclei  invested  with  a  layer  of  pro- 
toplasm), which  occur  still  more  rarely. 

The  bloodvessels  of  the  root-membrane  originate  from,  and 
have  their  exit  into,  three  different  localities,  viz. :  1,  numerous 
tufts  of  vessels  having  a  longitudinal  direction  are  given  off  from 
the  vessels  of  the  submucous  connective  tissue  of  the  gums  ;  2, 
similar  tufts  arise  from  the  dental  vessels  which  supply  the  pulp  ; 
3,  vessels  enter  from  and  empty  into  the  osseous  vessels  of  the 
porous  alveolar  wall.  These  relations,  which  have  been  men- 
tioned, are  much  more  clearly  perceptible  in  the  incisors  and 
canines  than  in  the  bicuspid  and  molar  teeth,  since  the  root- 
membranes  of  the  latter,  in  human  teeth,  but  more  particularly 
those  of  the  molars  of  larger  mammals,  have  a  less  smooth  ap- 
pearance, and,  where  the  roots  diverge,  are  thickened.  The  net- 
work of  capillary  vessels  presents  a  very  uniform  arrangement; 
the  separate  meshes  have  an  elongated  form  generally ;  are 
directed  towards  the  surface  of  the  root,  and  are  narrower  in 
the  vicinity  of  the  neck  and  apex  of  the  root. 

The  mteralveolar  vessels,  inclosed  in  a  porous,  osseous  canal, 
pursue  a  vertical  course  between  two  adjacent  dental  sockets, 

*  Memoires  sur  les  Tumeurs  du  Perioste  Dentaire,  1860. 


60  ANATOMY    AND    PHYSIOLOGY. 

and  are  accompanied  by  the  corresponding  narrow  bundles  of 
nerves  and  loose  connective  tissue.  The  distinctness  of  the 
interalveolar  canals  varies.  For  example,  the  foramina  leading 
to  the  interalveolar  canals,  which  may  be  seen  between  the  necks 
of  the  teeth  upon  the  lingual  wall  of  the  alveolar  process,  are 
quite  wide  in  the  jaws  of  young  persons,  and  become  obliterated 
with  increasing  age.  The  interalveolar  vessels  divide  into 
branches  at  their  exit  upon  the  margins  of  the  alveolar  process, 
and  supply  tlie  lingual  side  of  the  gum.* 

The  periosteum  of  the  root  is  supplied  with  a  rich  network 
of  nerves.  The  nerve-tubes  are  of  various  diameters,  very  thick 
and  thin  ones  being  united  together  into  bundles.  They  are 
branches  of  the  dental  and  gingival  nerves,  as  can  easily  be 
demonstrated,  and  in  part  also  are  composed  of  filaments  Avhich 
come  through  the  foramina  in  the  alveolar  Avails,  and  from  the 
interalveolar  canals. 

Development  of  the  Teeth. — In  order  to  render  this  sub- 
ject more  clear,  I  have  divided  the  phenomena,  in  the  order  of 
their  occurrence,  into  the  following  groups.  Human  embryos, 
at  so  early  a  period  as  the  second  month  of  pregnancy,  are 
rarely  available  for  histogenetic  investigations,  as  they  are 
generally  injured  by  maceration   after  the  death   of  the  ovum 

*  The  injection  of  the  inferior  alveoliir  arteries  is  most  easily  made  bj' 
forcibly  enlarging  the  posterior  portion  of  the  canal  of  the  inferior  maxillary 
bone  to  the  depth  of  a  few  lines,  when  the  artery  may  be  sought  for  and  at- 
tached to  a  fine  tube  corresponding  to  it  in  diameter.  The  mental  branch, 
as  it  emerges  from  the  mental  foramen,  should  either  be  tied  or  compressed, 
particularly  in  larger  animals,  while  the  injection  is  being  made.  On  ac- 
count of  the  anastomoses  existing  between  the  periosteal  vessels  and  those 
of  the  gum,  the  papillae  of  the  latter  also  will  be  filled.  The  under  jaws  of 
the  calf,  roe,  dog,  or  sheep,  are  well  adapted  for  injection.  The  delineation 
of  the  periosteal  vessels  of  the  roots  of  the  upper  teeth  is  more  minute,  inas- 
much as  the  alveolar  artery  of  the  superior  maxillary  bone  supplies  only  the 
bicuspid  and  molar  teeth,  the  incisors  and  canine  teeth,  on  the  other  hand, 
being  supplied  by  a  branch  of  the  infraorbital  artery.  Injections  of  the 
superior  alveolar  artery  will  extend  to  the  vessels  of  the  posterior  portion  of 
the  mucous  membrane  of  the  antrum  of  Highmore  and  the  nasal  cavity. 

The  capillary  vessels  of  the  periosteum  of  the  root  possess,  according  to 
the  assertions  of  Ch.  Robin,  an  epithelial  covering.  I.  too,  have  observed 
an  appearance  somewhat  like  this  upon  many  of  the  capillaries,  but  could 
not  convince  myself  of  its  constancy. 


DEVELOPMENT    OF    THE    TEETH.  61 

within  the  uterus.  It  is,  therefore,  generally  necessary  to 
employ  the  embryos  of  calves,  pigs,  sheep,  &c. 

1.  The  first  indication  of  the  commencement  of  the  develop- 
ment of  the  germ  is  afforded  by  a  fig.  ii.* 
proliferation  of  the  epithelial  struc-                   !'  ,' 

ture  of  the  mucous  membrane  cov-         "^ 
ering  the  edges  of  the    maxillary  " 

arches,  in  the  form  of  a  fold,  called  ''  ^-^.^ 

the  dental  ridge  (Marcusen),  which  ''-",  "- 

is   composed   of   several    layers    of         ^'^"'"'''"'''-'''^'ss,^^^'^' 
large,    flattened,    nucleated    cells,  c 

Corresponding  with  a  superficial,  shallow  groove,  which  appears 
upon  the  ridge,  the  mucous  layer  becomes  depressed  from  with- 
out inwards,  in  the  form  of  a  short  [on  transverse  section]  cul- 
de-sac,  which  is  tenanted  by  the  cells  of  the  latter  layer.  This 
tubular  depression  gradually  expands  in  the  form  of  a  pouch,  as 
its  development  progresses  interiorly,  while,  externally,  toward 
the  outer  surface  of  the  mucous  layer,  it  presents  a  narrowing 
or  constriction.  This  follicle  of  mucous  cells  was  demonstrated 
by  Kolliker  to  be  the  enamel  germ.  These  relations  are  most 
plainly  visible  in  the  incisors  (Fig.  11). 

Coincident  with  the  depression  of  the  epithelium  of  the  mucous 
layer  appears,  as  has  been  observed,  a  shallow  groove  upon  the 
dental  ridge,  called  the  dental  groove,  which  is  bounded  by 
two  elevated  borders  or  lips,  that  upon  the  facial  side  being  the 
more  prominent  of  the  two. 

2.  From  the  floor  of  the  pouch-like  expansion  of  the  enamel 
germ,  which,  upon  its  periphery,  is  covered  by  the  cells  of  the 
mucous  layer,  and  in  its  central  portions  is  occupied  by  ex- 
tremely delicate  nucleated  elementary  organs,  rises  a  papilliform 
process  of  connective  substance;  this  is  the  primary  stage  of  the 

*  Fig.  11. — Primary  stage  in  the  development  of  an  incisor  of  the  lower 
jaw  ;  from  the  ombrj'o  of  a  calf.  Section  made  perpendicular  to  the  arch  of 
the  jaw.  (a)  Dental  ridge,  consisting  of  large  epithelial  cells;  from  the 
mucous  surface  of  the  epithelium,  a  follicular  process  (6),  which  already 
presents  a  constricted  neck  and  is  lined  throughout  with  epithelium,  extends 
from  without  inwards,  and  is  the  rudiment  of  the  enamel  germ  ;  (c)  epi- 
thelium of  the  margin  of  the  under  lip,  with  rudimentary  hair-follicles; 
[d)  osseous  trabeculie  covered  with  periosteum.     Magnified  15  diameters. 


62  ANATOMY    AND    PHYSIOLOGY. 

dentinal  germ,  and  appears  as  a  single  papilla  Avlien  it  represents 
an  incisor  or  canine  tooth,  and  as  an  elevation  with  several  cusp- 
like  processes  when  it  represents  the  deciduous  molars.  As  the 
neck  of  the  enamel  germ  becomes  more  elongated,  its  walls  be- 
come broken  up  into  folds,  which  are  lined  throughout  with  the 
cells  from  the  mucous  layer  and  give  to  the  neck  an  appearance 
^     ,.,^  like  that  of  a  follicular  gland  with  lat- 

.«k:^v,^-,.,...  „.^^,         eral  offshoots.     At  a   definite    distance 

'      ^  "^         from  the  surface  of  the  dentinal  germ  a 

shaded  lunated  outline  becomes  visible, 
which  is  the  primary  stage  of  the  dental 
\  I  "\      sac  (Fig.  12). 

§'  -  .3.    The   development   of   the   enamel 

■    :;  7|i^ ,  germ,  which   becomes   directed  towards 

the  face  and  undergoes  a  flexion  in  its 
^^  -  constricted  portion,  now  goes  on  to  com- 

'-  pletion.     As  the  enamel  germ  increases 

"  in  volume,  and  the  dentinal  germ  is  devel- 

oped from  below  upwards,  more  and  more  into  the  follicle,  the 
former  comes  to  invest  the  dentinal  germ  like  a  cap.  A  diifer- 
entiation  of  the  tissue  of  the  enamel  germ  ensues,  which  gives 
rise  to  a  structure  consisting  of  several  layers,  the  so-called 
enamel  organ.  In  consequence  of  the  above-mentioned  upward 
development  of  the  conical  dentinal  germ,  and  the  gradually  in- 
creased invagination  of  the  follicle,  the  peripheral  epithelial 
layer  of  the  latter  becomes  separated  into  an  external  and  an 
internal  lamina,  the  external  epithelium  (Thiersch)  and  the  in- 
ternal. The  latter  is  disposed  upon  the  dentinal  germ,  the 
former  upon  the  roof  of  the  dental  sac.  Between  the  two  epi- 
thelial laminjB  lies  an  intermediate  layer. 

*  Fig.  12  shows  the  davelopment  of  an  enamel  germ,  with  numerous 
folds,  of  a  lower  bicuspid  from  the  embryo  of  a  calf.  Transverse  section. 
The  mucous  lajer  of  epithelium  sinks  into  the  mucous  membrane,  forming 
several  secondary  sinuations,  and  expands  in  the  form  of  a  sac,  iiaving 
numerous  folds,  being  surrounded  everywhere  by  connective  tissue.  The 
cells  lining  the  walls  of  the  follicle  have  a  cylindrical  form  («).  The  cells 
of  the  interior  are  small  and  flattened.  Tlio  rudiment  of  the  dental  sac  is 
indicated  by  a  shaded  outline  [b).  Between  a  and  b  the  rudiment  of  the 
dentine  is  elevated  into  papilliform  processes.     Magnified  80  diameters. 


DEVELOPMENT    OF    THE    TEETH. 


63 


Fir.  13* 


The  enamel  organ  acquires  a  gelatinous  appearance,  contains 
no  vessels,  and  becomes  thinner  as  it  approaches  the  base  of  the 
cap,  at  the  summit  of  which  also  it  is  generally  somewhat  thinner 
than  it  is  below.  The  thinnest  portion  is  met  with  at  the  base 
of  the  cap,  at  the  place  of  reflection,  where  the  external  and 
internal  epithelium  are  in  close  proximity.  It  is  composed  of 
three  principal  laminoe :  {a)  the  internal  epithelial  layer,  also 
called  the  lai/er  of  enamel  cells,  which  is  composed  of  elongated 
conical  cells,  with  their  broad  extremities  directed  toward  the 
developing  enamel,  while,  on  the  other  hand,  the  narrow  ex- 
tremities unite  with  spindle-shaped  formative  or  reparative  cells 
(Ersatzzellen),  or  are  inserted  between  them.  The  enamel  cells, 
as  well  as  their  obliquely  arranged 
formative  cells,  inclose  a  granular 
protoplasm  and  an  oval  nucleus,  a 
The  formative  colls  are  connected 
by  means  of  a  filamentous  layer 
with  the  second  principal  lamina  (/:>), 
the  spongy  tissue.  This  forms  the 
principal  mass  of  the  enamel  organ, 
and  its  transparent  basis-substance 
is  occupied  by  cells  with  stelliform 
radiating  processes.  The  bodies  of 
the  cells  inclose  an  oval  nucleus ; 
the  processes  unite  to  form  a  net-  '^ 
work,  the  meshes  of  which  become 
more  narrow  from  within  outwards, 
and   are   in   relation  with  an  inter- 


*  Fig.  13. -^Transverse  section  of  the  enamel  organ  of  an  incisor  from  a 
human  foetus,  tiie  section  taken  from  the  vicinity  of  the  reflection  of  the  cap, 
where  the  organ  has  already  become  quite  thin,  (a)  Enamel  cells  (ex- 
ternal [?J  epithelium),  with  the  gradually  more  obliquely  disposed  formative 
cells  (Ersatzzellen),  which  ultimately  assume  a  liorizontal  direction,  and 
become  spindle-shaped  ;  (/;)  multiradiating  flattened  cells,  which  form  a  net- 
work by  means  of  their  connecting  processes,  and  belong  to  the  spongy 
layer;  (c)  layer  of  spindle-shaped  cells,  with  oblong  nuclei,  analogous  to 
those  adjoining  the  layer  of  enamel  cells;  [d)  groups  of  cells  belonging  to 
the  external  epithelium,  and  lying  in  sac-like  cavities  ;  between  the  groups 
are  the  openings  of  capillary  bloodvessels.  The  papillie  of  the  dental  sac,  on 
account  of  their  oblique  position,  are  represented  obliquely  within  the  sec- 
tions;  (f)  lax  connective  tissue  of  the  dental  sac.    Magnified  400  diameters. 


64 


ANATOMY    AND    PHYSIOLOGY, 


Fio.  14.* 


mediate  layer  composed  of  horizontally  disposed  spindle-shaped 
cells.  Outside  of  the  latter  appears  {e) 
a  group  of  cells,  called  the  external  epi- 
thelium, which  invest  the  papilite  pro- 
jecting into  the  enamel  organ  from  the 
wall  of  the  dental  sac  (Fig.  13). f 

The  dental  sac,  from  the  floor  of  which 
proceeds  the  dentinal  germ,  is  developed 
opposite  the  surface  of  the  latter,  and  in- 
vests it  and  the  enamel  germ,  forming  a 
connective  tissue  envelope  around  the 
two,  the  continuity  of  which  is  broken 
only  at  that  part  which  has  been  de- 
scribed as  the  constricted  portion  or  neck  of  the  enamel  germ, 
and  is  connected  with  the  mucous  layer  of  the  epithelium.     It 

*  Fig.  14. — Injected  bloodvessels  from  the  dental  sac  of  a  new-born  child. 
The  larger  ones  lying  outside  form  a  network,  with  elongated  meshes.  In- 
teriorly, delicate  capillaries  are  given  off  and  form  anastomotic  loops,  here 
and  there,  directed  toward  the  enamel  organ.     Magnified  30  diameters. 

f  The  spong}^  tissue  was  formerly  considered  to  be  a  gelatinous  connective 
tissue,  until  Huxley  and  KoUiker  demonstrated  that  it  is  to  be  classed  with 
the  epithelial  structures.  Opinions  are  still  divided  as  to  the  manner  in 
vvliicli  the  enamel  is  developed  out  of  the  enamel  cells.  One  theory,  which 
I  also  uphold,  maintains  that  it  is  by  the  direct  calcification  of  the  enamel 
cells,  and  Waldeyer  (S.  Strieker's  Handbuch  der  Gewebelchre)  adduces,  as 
strong  evidence  in  support  of  this  view,  the  occurrence  of  enamel  cells  and 
fragments  of  enamel  prisms  in  intimate  connection,  the  latter  remaining 
adherent  to  the  former  in  the  form  of  processes.  According  to  his  view  pet- 
rifaction (petrifiziren)  of  the  enamel  cells  commences  in  the  investing  zone, 
while  the  axial  portion  of  the  protoplasm  retains  its  softness  for  a  time,  and 
in  is-olated  cells  forms  a  kind  of  process  (Tomes'  Processes  of  the  Enamel 
Cells).  The  other  view,  which  Kolliker  furmerly  held,  is  ba^ed  upon  the 
idea,  that  the  enamel  is  a  cuticular  structure.  Guillot,  Robin,  and  Magitot, 
as  the  I'esult  of  their  investigations  with  reference  to  this  subject,  assert  that 
the  teeth  and  their  appendages  are  developed  in  the  submucous  tissue, 
entirely  free  and  independent  of  all  other  tissues.  Max  Eeichert,  also,  was 
inclined  to  this  erroneous  view  (Dubois-Reichert's  Archiv,  18G9),  according 
to  whom,  the  enamel  organ  originates  from  the  corium,  and  not  from  the 
epithelium  of  the  mucous  membrane  of  the  mouth.  The  gelatinous  tissue, 
together  with  the  stellate  cells  of  the  enamel  organ,  he  regards  as  connec- 
tive tissue.  Kollmann  has  recently  published  a  work,  agreeing  essenti- 
ally with  KoUiker's  theories  (Entwicklung  der  JMilch-  und  Ersatzzahne, 
Zeitschr.  f.  wiss.  Zoologie,  Bd.  20). 


DEVELOPMENT    OF    THE    TEETH.  65 

is  closed,  at  a  quite  early  period,  in  the    manner  already  de- 
scribed, before  there  is  the  least  trace  of  the  tooth  cap.     It  be- 
comes richly  supplied  with  bloodvessels  and  nerves.     That  por- 
tion of  the  sac,  particularly,  which  invests  the  enamel   organ, 
becomes  elevated  into  rows  of  papillary  excrescences  which  are 
covered  by  the  cells  of  the  external  epithelium  of  the  developing 
enamel  organ.    The  wall  of  the  sac  is  divided  into  a  compact  pe- 
ripheral or  outer,  and  an  inner  lamina  of  a  more  lax  tissue.    It  is 
traversed  by  numerous  interlacing  bundles  of  nerves,  and  the 
bloodvessels  also  are  very  abundant ;   the  larger  of  these  are 
distributed  in  the  outer,  and  the  smaller  in  the  inner  lamina. 
As  they  pursue  a  generally  straight  course,  they  give  rise  to 
oblong  meshes  (Fig.   14).     In  that  lamina   of   the   dental   sac 
which  is  in  relation  with  the  enamel  organ,  capillaries  extend 
into  the  corresponding  papillse,  where  they  form  anastomotic 
loops.     These  vascularized  papillae  are  so 
intimately  united  with  the  enamel  organ, 
that,  together  with  the  anastomotic  loops,        4pl^^,^/hi&Mj> 
they  remain  adherent  to  the  enamel  organ        j,       s'^'lf^'^*/) 
after   the   dental   sac   has   been  detnched        uyjO^^i-^      j,  '<-k! 
(Fig.  15). 

The  dentinal  germ  receives  bloodvessels 
and  nerves  from  that  portion  of  the  dental 
sac  with  which  it  is  in  contact,  and  becomes 
developed  into  one  or  several  papillne  or 
prominences,  according  to  the  number  of 
tubercles  which  the  crown  is  to  present.  Consequently  the 
rudiments  of  canine  teeth  present  one,  and  those  of  molar  and 
bicuspid  teeth  several  papill;i3.  Well-developed  dentinal  cells 
with  their  processes,  such  as  have  been  described  in  connection 
with  the  pulp,  are  observed  at  a  comparatively  early  period. 
Large  vascular  twigs  extend  up  and  down  from  the  base  of  the 
germ,  and  ramify  in  various  directions  towards  its  surface,  where 

*  Fig.  15. — Injected  capillaries  which  remained  adherent  to  the  enamel 
organ  of  a  bicuspid  tooth,  from  a  calf,  the  dental  sac  having  been  detached. 
The  anastomotic  loops  have  been  torn  from  their  connection  with  the  vessels 
of  the  dental  sac,  and  reach  almost  to  the  layer  of  enamel  cells.  Magnified 
30  diameters. 

5 


QQ 


ANATOMY    AND    PHYSIOLOGY. 


Fig.  16.* 


they  terminate  in  loops.    The  latter  pursue  a  straight  course  in 
young  germs  (Fig.   16).     The  connective  tissue  of  the  germ  is 
very  soft,  contains  numerous  cells,  and  be- 
comes exceedingly  cloudy  on  the  addition 
of   acetic  acid.     The  dentinal   cap,  ■which 
primarily  is  exceedingly  thin,  is  blended 
with  the  enamel  cap,  while,  from  the  be- 
ginning, the  enamel  and  dentine  are  devel- 
oped in  opposite  directions.     The  dentine 
is  formed  by  the  deposition  of  new  layers 
from  without  inwards,  while  the  enamel,  as 
above    demonstrated,    is    developed    in    a 
similar  manner  from  within  outwards. 
The  enamel  germ  of  a  permanent  tooth, 
which  has  a  single  root,  is  developed,  at  an  early  period,  upon 
the  lingual  side   of  the    milk   teeth,  in 
the  form  of  a  cul-de-sac.     It  commences 
in    the    form    of    a    direct    depression 
of  the  mucous  layer  of  the  epithelium 
from    the  dental    groove,   between   the 
facial    and   lingual  lips    of    the  dental 
ridge,  and   has   a   common   origin   with 
the  enamel  germ  of  the  milk  tooth  (Fig. 
17).     The  follicle  presents  lateral  folds, 
which  not  unfrequently  occur  in  large 
numbers.     The  closed"  terminal  portion 
of  the  follicle  was  recognized  by  Kol- 
liker  as  the  enamel  germ  of  the  perma- 
nent tooth.     The  connecting  branch  of 
the   follicle,    which    extends   outwardly 
towards  the  face,  is  in  direct  communi- 
cation with  the  external  epithelium  of 
the  enamel  orfjan  of  the  deciduous  tooth. 


*  Fig.  16. — Injected  terminal  loops  from  the  pulp  of  a  permanent  incisor 
of  a  new-born  child.  The  vessels  pursue  a  straight  course.  The  loops  are 
partly  single  and  partly  complex.     Magnified  30  diameters. 

f  Fio.  17  shows  a  follicle  of  mucous  cells  extending  from  the  dental  ridge 
to  the  enamel  germs  of  the  milk  and  permanent  teeth  ;  from  a  human  embryo 
of  three  months'  growth.     The  cells  of  the  raucous  layer  of  epithelium  dip 


DEVELOPMENT    OF    THE    TEETH. 


67 


The  connection  of  the  outer  with  the  inner  epithelium,  as  well 
as  a  general  view  of  the  developing  crown,  the  tooth  cap,  and 
the  dental  sac,  together  with  the  parts  in  the  immediate  vicinity, 
may  be  observed  in  sections  of  the  jaws  of  embryos  of  a  suitable 
age,  which  have  been  decalcified  by  means  of  diluted  hydro- 
chloric and  chromic  acids.  The  inner  epithelium  commences  at 
the  base  of  the  dentinal  germ  (Fig.  18),  and  extends  along  the 


Fig.  18.* 


down  into  tlie  substance  from  the  dentul  groove  (a)  of  an  incisor  of  the  lower 
jaw,  and  resemble,  somewhat,  a  tubular  gland  with  lateral  ottViicots.  At 
about  the  middle  of  the  follicle,  which  is  lined  throughout  with  cylindrical 
cells,  it  is  connected  by  a  transverse  process  {/>)  witii  the  external  epithelium 
of  the  enamel  organ,  the  spongy  layer  of  which  is  represented  (<•].  The 
inferior  closed  portion  of  the  follicle  is  the  enamel  germ  of  the  permanent 
incisor  tooth.     Magnified  80  diameters. 

*  Fig.  18. — Sagittal  ^ection  of  a  lower  jaw  from  the  embryo  of  a  dog, 
showing  an  incisor  within  its  dental  sac.  (a)  Facial  lip  of  the  dental  ridge; 
(6)  epithelium  ;  (c)  corium,  with  papillae  in  the  dental  ridge,  and  cavities  of 
transversely  divided  vessels;  {d)  enamel  germ  of  the  permanent  incisor 
containing  an  aggregation  of  epithelial  cells;  its  connection  with  the  enamel 


68  ANATOMY    AND    PHYSIOLOGY. 

entire  outer  surface  of  the  dental  cap.  The  thickness  of  the 
pulp  bears  a  direct  relation  to  that  of  the  cap  ;  that  is  to  say, 
the  thicker  the  former,  the  thinner  the  latter  ;  and  the  pulp 
rests  upon  the  floor  of  tlie  dental  sac.  The  latter  has  a  rounded 
form,  corresponding  with  the  developing  dental  crown,  lies  be- 
neath the  facial  lip  of  the  dental  ridge,  within  the  maxillary- 
groove,  and  is  intimately  connected  with  the  exceedingly  vascu- 
lar and  nervous  submucous  connective  tissue  of  the  gum,  and 
with  the  layer  of  connective  tissue  which  lines  the  maxillary 
groove.* 

organ  of  the  decidiious  tooth  does  not  appear  in  the  section  ;  (e)  anterior,  (e') 
posterior,  osseous  lamelhi  of  the  jaw  with  rounded  summits;  (/)  completed 
enamel  of  the  dental  cap  ;  in  the  section  it  is  separated,  somewhat,  from  the 
(9)  layer  of  enamel  cells;  (A)  retiform  connective  tissue  of  the  dental  sac; 
(i)  outer  epithelium  of  the  enamel  organ  completely  investing  the  papillae 
of  the  dental  sac;  {k)  spongy  layer  of  the  enamel  organ;  (I)  completed 
dentine  of  the  cap;  (>«)  layer  of  dentinal  cells  ;  (n)  dental  pulp  with  wide 
vessels  in  its  interior.     Magnified  20  diameters. 

*  The  mode  of  development  of  the  dentine  is  so  far  determined  that  we 
know  positively  that  the  dentine  is  developed  from  the  dentinal  cells.  We 
may  also  readily  demonstrate  that,  as  soon  as  the  connection  of  the  dentinal 
with  their  formative  cells  occurs,  the  calcification  of  the  contents  of  the 
dentinal  cells  begins ;  that  their  principal  and  accessory  processes  remain 
attached  and  are  transformed  into  dentinal  fibres,  and  that  a  constant  depo- 
sition of  calcareous  salts  into  the  cells  takes  place  from  the  blood. 

Bj'  the  continuous  transformation  of  formative  cells  into  dentinal  cells, 
the  process  goes  on,  and  new  layers  of  dentine  are  deposited  constantly  by 
progressive  calcification.  Kolliker  (op.  cit.)  maintains  another  view,  a 
modification  of  the  last,  namely,  that  the  calcified  substance,  which  is  found 
between  the  dentinal  fibrils  (basis-substance,  or  matrix,  of  the  dentine),  is  to 
be  considered  an  excretion  from  the  dentinal  cells,  and  consequently  is  not  a 
product  of  the  immediate  calcification  of  the  latter. 

Another  question  arises,  viz.,  how  do  the  globular  masses  originate,  and 
what  relation  do  they  bear  to  the  normal  development  of  the  dentine?  The 
globular  masses  found  on  the  inner  surface  of  the  dentine  of  the  teeth  of 
children  are  permeated  by  dentinal  canals,  and  in  accordance  with  the  first 
theory  may  be  considered  to  be  the  result  of  a  coalescence  of  separate  groups 
of  calcified  dentinal  cells.  There  are  two  possibilities,  in  regard  to  the 
globular  masses  which  are  intercalated  between  the  systems  of  dentinal 
canals,  without  being  pierced  by  them,  namely:  that  in  these  localities  the 
processes  within  the  groups  of  calcified  cells  were  prematurely  destroyed,  or 
that,  in  consequence  of  an  arrest  of  development,  tlie  process  of  calcification 
of  the  dentinal  cells  progressed  merely  to  the  formation  of  globules  of  cal- 
careous salts. 


DEVELOPMENT    OF    TUE    TEETH.  69 

4.  The  dental  cap,  considered  as  the  aggregate  of  calcified 
dentinal  and  enamel  cells,  maintains  during  its  development  the 
shape  given  to  it  by  the  arrangement  of  the  cells  ;  it  increases 
in  thickness,  and  eventually  becomes  the  crown  of  the  tooth ; 
contemporaneous  with  the  growth  of  the  latter  the  enamel  organ 
gradually  becomes  thinner,  and  finally  shrivels  up  completely. 
When  the  development  of  the  crown  is  accomplished,  that  is, 
when  no  new  layers  of  enamel  are  formed,  the  growth  of  the 
radical  portion  of  the  tooth,  from  the  edge  of  the  crown,  com- 
mences;  the  dentinal  cells  adopt  a  more  horizontal  position, 
and  consequently  the  dentinal  canals  also  assume  a  more  hori- 
zontal direction.  At  the  margin  of  the  crown  the  dental  sac 
contracts,  and  upon  its  inner  surface  the  formation  of  the  cement 
is  effected,  increasing  gradually  as  the  formation  of  the  root 
advances  ;  the  lower  segment  of  the  dental  sac  becomes,  there- 
fore, the  root-membrane  of  the  tooth. 

Contemporaneous  with  the  latter  processes  occurs  the  formation 
of  Nasmytlis  enamel  membrane,  which  is  interpreted  in  various 
ways.  This  membrane,  called  by  Ivolliker  the  cuticle  of  the 
enamel,  is  considered  by  him  to  originate  in  this  manner,  viz.: 
that  an  additional  coherent  layer  (cuticle)  is  secreted  by  the 
enamel  cells,  after  the  completion  of  the  formation  of  the  enamel, 
to  serve  as  a  protection  for  the  whole.  Waldeyer  regards  it  as 
the  product  of  the  cornification  (Verhornung)  of  cells.  J.  Tomes 
holds  the  opinion,  that  the  membrane  belongs  to  the  cement, 
because  it  is  continuous  from  the  crown  upon  the  cement,  as 
ma}'^  be  demonstrated  on  teeth  which  have  been  treated  with 
dilute  hydrochloric  acid  ;  moreover,  the  membrane  is  thickened 
in  the  depressions  upon  the  crowns  of  the  molars,  and  in  these 
localities  distinct  bone-corpuscles  likewise  occur.  These  argu- 
ments, together  with  data  furnished  by  comparative  and  patho- 
logical anatomy,  uphold  the  latter  view,  in  my  opinion.  In  the 
development  of  teeth  with  irregularities  in  the  enamel,  the  adap- 
tations of  the  dental  sac  and  the  enamal  organ  to  depressions  in 
the  crowns  may  easily  be  demonstrated,  and  there  remains, 
finally,  an  outer  covering  of  cement  upon  the  masticating  sur- 
faces of  the  crowns.  The  case  illustrated  in  the  Atlas,  Fig.  9, 
where  the  radical  cement  passes  without   interruption   into   a 


70 


ANATOMY    AND    PHYSIOLOGY. 


well-marked  coronal  cement,  whicli  covers  the  entire  masticating 
surface  and  insinuates  itself  between  the  folds  of  enamel,  is  ex- 
plained by  the  latter  theory, 

5.  The  growth  of  the  pulp  root  and  the  contiguous  zones  of 
the  dentine  keeps  pace  with  the  formation  of  the  cement  which 
takes  place  externally  to  the  latter.  While  the  growth  of  the 
dentine  in  thickness  gradually  diminishes,  that  of  the  cement 
increases.  As  the  peripheral  portions  of  the  dentine  are  always 
formed  first,  it  will  readily  be  understood  why  an  incomplete 
root  presents  at  its  extremity  a  sharp  margin  and  a  dome-shaped 
cavity,  called  by  the  dentists  an  unclosed  root.  The  formation 
of  the  root  is  completed  when  its  canal  no  longer  presents  a 
funnel-shaped  expansion  at  its  extremity. 

6.  The  development  of  the  osseous  walls  of  the  teeth  is  first 

indicated  by  an  osseous  dental  groove,  which  is  more 
fk..  19.*  distinctly  marked  upon  the  lower  jaw,  and  is  inclosed 
by  a  facial  and  lingual  lip.  It  is  shallow  and  flattened 
posteriorly  (Fig.  19).  As  this  groove  becomes  deeper 
and  wider,  lamellar  projections  appear  upon  its  interior 
wall,  the  first  making  its  appearance  between  the  two  dental 
sacs  of  the  incisors.  At  about  the  same  time,  flattened  spinous 
processes  also  appear  toward  the  upper  margins  of  both  the 
labial  and  lingual  walls  (Fig  20  a).  These  processes  grow 
towards  one  another  and  gradually  complete  the  continuity  of 

the  wall.  In  this  way  an  osse- 
ous case,  of  a  fine  spongy  tex- 
ture, is  formed  around  the  den- 
tal sac,  which  gradually  con- 
tracts,but  remains  permanently 
open  externally.  It  may  be 
demonstrated  separately,  and 
is  called  the  bont/  socket,  or 
alveolus  of  the  dental  crown. 
The    size,    position,    and    re- 

*  Fig.  19. — Lower  jaw  of  a  human  foetus,  at  the  commencement  of  the 
third  month  of  pregnancy,  seen  from  above,  in  order  to  give  a  view  of  the 
groove  in  the  bone,  which  becomes  flattened  from  before  backwards.  The 
coronoid  processes  and  cond^yles  are  already  indicated.     Natural  size. 

f  Fig.  20,  a. — Macerated  left  half  cf  the  inferior  maxillary  arch,  from  a 


Fig.  20.    a,  b.f 


DEVELOPMENT    OF    THE    TEETH.  71 

spective  distances  of  the  sockets  from  each  other  can  be  demon- 
strated to  the  best  advantage  in  sections  of  decalcified  jaws, 
corresponding  with  their  curves.  All  the  cells  are  equidistant 
from  the  edge  of  the  gum,  while  their  distance  from  the  inferior 
margin  of  the  lower  jaw  decreases  from  before  backwards,  that 
is,  the  socket  of  the  middle  incisor  is  most  distant,  and  that  of 
the  second  molar  is  nearest,  which  relation  corresponds  with  the 
growth  of  tlie  bone  in  depth  from  before  backwards  (Fig.  20  b). 
When  the  growth  of  the  root  commences,  and  the  corresponding 
segment  of  the  dental  sac  becomes  the  root-membrane  from 
which  the  cement  originates,  a  partial  process  of  resorption 
takes  place  in  the  osseous  coronal  sockets.  This  is  but  a  tem- 
porary process,  and  continues  only  so  long  as  the  crown  is  in 
an  embryonic  condition.  As  far  as  I  know,  Tomes  was  the  first 
to  call  attention  to  the  important  circumstance,  to  be  considered 
later,  namely,  the  fact  that  resorption  of  a  portion  of  the  walls 
of  the  alveoli  ensues  in  order  to  prepare  the  way  for  the  passage 
of  the  teeth  through  the  gum. 

7.  The  formation  of  the  twenty  osseous  alveoli  of  the  crowns 
is  nearly  completed  in  the  eighth  month  of  pregnancy,  only  the 
facial  walls  of  the  alveoli  of  the  canine  teeth,  and  the  posterior 
Avail  of  the  second  deciduous  molar,  particularly  in  the  upper 
jaw,  remaining,  for  the  most  part,  membranous.  Consequently 
the  osseous  septum  between  the  second  deciduous  and  first  per- 
manent molar  is  wanting.  Since  the  posterior  are  considerably 
wider  than  the  anterior  alveoli,  it  will  be  seen  that  the  facial 
lamina  of  the  alveolar  process  of  the  upper  jaw  describes  a  wide 


fa>tus,  at  the  seventh  month  of  pregnancy.  View  from  the  lingual  side. 
The  partitions  or  septa  for  the  incisors  are  partially  formed  ;  the  facial  wall 
of  the  canine  tooth  still  presents  a  gap.  The  septa  for  the  milk  molars  are 
indicated  by  slight  ridges;  that  for  the  first  permanent  molar  is  already  per- 
ceptible towards  the  coronoid  process.     Natural  size. 

Fig.  20,  b. — Left  half  of  the  inferior  maxillary  arch,  from  a  new-born 
child ;  decalcified  by  means  of  dilute  hydrochloric  acid,  and  bisected  by  an 
incision  corresponding  with  its  curve.  The  incised  surface  of  the  outer  half 
is  exposed  to  view  ;  the  dental  sac  and  contents  are  removed.  The  separate 
walls  for  the  dental  sacs  of  the  milk  teeth  are  completely  developed  ;  the 
septum  for  the  first  permanent  molar  is  seen  to  be  partially  developed  within 
the  coronoid  process.     Natural  size. 


72  ANATOMY    AND    PHYSIOLOGY. 

and  semicircular  curve,  internal  to  which  lies  the  narrower  semi- 
elliptical  bow  of  the  lingual  lamina.  In  the  lower  jaw  the 
lamiuiB  of  the  alveolar  process  extend  nearly  parallel  to  each 
other,  from  before  backwards ;  the  anterior  segments  extend 
from  the  median  line  outwards ;  behind  the  alveoli  of  the  canine 
teeth  they  bend  abruptly  backwards,  and  thus  describe  curves 
similar  to  the  letter  S  ;  the  posterior  extremities  of  the  two 
rami  of  the  lower  jaw  consetiuently  present  a  greater  divergence 
than  those  of  the  upper. 

If  the  inferior  maxillary  arch  be  examined  from  below  at  this 
same  period  of  development  (the  eighth  month),  in  its  relation 
to  the  superior  arch,  both  jaws  being  left  in  their  natural  posi- 
tion so  that  the  suture  of  the  palatal  processes  and  the  symphisis 
of  the  lower  jaw  lie  in  the  same  perpendicular  plane,  the  greater 
divergence  of  the  posterior  segments  of  the  inferior  arch  will  be 
perceptible.  A  profile  view  presents  a  notable  projection  of  the 
upper  beyond  the  lower  jaw,  an  appearance  occasioned  in  part 
by  the  fact  that  the  mental  process  is  not  yet  developed. 

The  alveoli  for  the  cj-owns  of  the  incisors  are  broader  on  the 
facial  than  on  the  lingual  side.  While  they  expand,  with  the 
growth  of  the  crown,  their  orifices  upon  the  alveolar  ridge  become 
contracted,  because  the  facial  and  lingual  walls,  as  they  are  de- 
veloped from  below  upward,  incline  toward  each  other.  The 
alveoli  of  the  canine  teeth  are  characterized  externally  by  a 
prominent  ridge,  the  canine  eminence,  and  generally  bulge  more 
than  the  other  sockets.  Their  facial  walls  in  the  upper  jaw  are 
almost  entirely  ossified  at  the  commencement  of  the  second 
month  after  birth.  The  openings  leading  to  the  oblong  alveoli 
of  the  milk  molars,  particularly  that  of  the  second  molar,  are 
wide  at  first,  but  later  contract  gradually.  In  the  first  months 
after  birth,  the  facial  and  lingual  walls,  together  with  the  septa 
between  the  alveoli,  are  developed  from  below  upward,  and  in- 
cline toward  each  other.  The  margins  of  each  of  the  sockets, 
in  the  course  of  their  development,  present  a  concavity,  at  first 
usually  slight,  but  still  perceptible,  which  is  the  result  of  com- 
mencing resorption.  These  taken  together  give  rise  to  the 
festooned  appearance  of  the  edges  of  the  alveolar  borders.    The 


FIRST    DENTITION.  73 

latter  conformation  is  exhibited  first  of  all  and  most  distinctly 
bj  the  alveoli  of  the  incisors. 

First  Dentition. — The  growth  of  the  root  in  length  keeps 
pace  with  the  process  of  resorption  at  the  alveolar  borders.  The 
crown  presses  against  its  membranous  covering,  and  becomes 
perceptible  to  the  touch  externally,  as  the  so-called  tooth  prom- 
inence (Zahnpille).  In  consequence  of  the  continuous  pressure 
of  the  crown  upon  the  vessels  and  nerves  of  the  summit  of  the 
dental  sac,  the  latter  undergoes  complete  atrophy  ;  the  inter- 
lacing bundles  of  connective  tissue 
acquire  a   dried  and  tense  appear-  ^'*^'  "^'^ 

ance  and  a  yellowish  color.  That 
part  of  the  gum  Avhich  is  in  im- 
mediate relation  with  the  dental 
sac  undergoes  a  similar  process,  its 
numerous  vessels  being  subjected 
to  extreme  tension  (Fig.  21).  The 
membranous  coverings  gradually 
become  thinner,  and  at  last  trans- 
parent, when  the  edge  of  an  incisor,  or  the  tubercles  or  cusps  of 
the  canine  and  molar  teeth,  are  exposed  to  view.  On  account 
of  the  constant  onward  pressure  of  the  crown,  which  is  com- 
mensurate with  the  advancing  growth  of  the  root,  the  gum  neces- 
sarily recedes  and,  after  the  eruption  of  the  crown  is  completed, 
attaches  itself  to  the  neck  of  the  tooth,  by  which  means  its  sub- 
mucous la^'^er  maintains  its  connection  with  the  dental  sac,  which 
latter  becomes  the  root-membrane. 

The  preparation  for  the  eruption  of  the  central  incisors  is 
manifested  by  the  above-mentioned  process  of  resorption,  which 
gradually  becomes  more  evident,  upon  the  lingual  and  facial 
walls  of  their  alveoli,  by  an  increase  in  the  concavity  of  their 
margins.  Recently  cut  incisive  edges  of  the  central  and  lateral 
deciduous  incisors  present  two  shallow  indentations.  The  re- 
sorption upon  the  alveolar  margins  of  the  lower  incisors  is  much 

*  Fig.  21. — Injected  gingival  bloodvessels  of  the  prominence  (Zahnpille) 
over  the  molar  of  a  new-born  sheep.  View  from  above.  The  vessels  con- 
verge toward  the  summit,  where  a  capillary  network  is  presented.  Magni- 
fied 5  diameters. 


74  ANATOMY    AND    PHYSIOLOGY. 

more  evident  at  first  than  it  is  on  those  of  the  upper.  The  re- 
sorption of  the  latter,  however,  soon  follows,  and  commonly  is 
more  conspicuous  on  the  facial  than  on  the  lingual  walls  of  milk 
teeth. 

The  central  incisors  advance  perpendicularly,  while  the  lateral 
incisors  present  a  lateral  inclination  of  the  facial  coronal  sur- 
faces, which  is  more  decided  when  still  inclosed  within  their 
bony  capsules  than  is  the  case  after  their  eruption  ;  they  must, 
therefore,  during  the  latter  process,  be  twisted  considerably 
toward  the  median  line  of  the  jaw. 

The  first  milk  molai's  generally  are  cut  in  the  first  months  of 
the  second  year,  and  not  unfrequently  earlier  in  the  upper  than 
in  the  lower  jaw.  When  the  masticating  surfaces  of  these  teeth 
have  already  advanced  to  their  proper  level  in  the  dental  range, 
their  roots  are  barely  half  formed,  and  the  extremities  of  the 
latter  present  a  wide  cavity  and  a  sharp  edge.  While  the 
canine  teeth  are  still  deeply  imbedded  in  the  jaw,  within  their 
alveoli,  they  present  the  most  notable  inclination  of  all  the 
teeth,  their  crowns  being  inclined  toward  the  median  line  of  the 
jaw,  and  their  necks  laterally.  As.  they  approach  the  summit 
of  the  alveolar  ridge,  they  experience  a  slight  lateral  inclination 
in  order  that  they  may  advance  in  the  space  between  the  lateral 
incisors  and  first  molars.  Another  peculiarity  of  the  canines  is 
afforded  by  the  fact  that  they  lie  farthest  from  the  alveolar 
ridge  and  consequently  are  obliged  to  traverse  the  greatest 
distance  in  order  to  reach  it.  There  is,  however,  another  cir- 
cumstance which  is  very  much  in  their  favor,  namely,  that  the 
resorption  upon  their  alveolar  margins  extends  higher  in  the 
upper,  and  deeper  in  the  under  jaws  than  is  the  case  with  the 
remaining  teeth.  When  their  eruption  has  progressed  so  far 
that  the  coronal  extremities  have  reached  the  level  of  those  of 
the  adjacent  teeth,  the  roots  have  barely  attained  half  their 
final  length. 

The  second  upper  molars  not  unfrequently  make  their  appear- 
ance before  the  corresponding  lower  teeth.  With  these,  the 
first  set  of  teeth,  the  milk  or  deciduous  set  is  completed,  gener- 
ally by  the  end  of  the  second,  or  occasionally  not  until  the 
end  of  the  third  year. 


FIRST    DENTITION.  75 

When  the  crowns  of  all  the  milk  teeth  have  attained  their 
full  growth  and  proper  relations,  tlie  growth  of  the  roots  is 
still  more  or  less  incomplete,  in  proportion  to  the  early  or  late 
eruption  of  their  respective  crowns.  Even  the  extremities  of 
the  roots  of  the  central  incisors  are  scarcely  closed  at  this 
period. 

The  periods  at  which  the  eruption  of  the  milk  teeth  com- 
mences and  terminates  vary  considerably.  While,  in  rare  cases, 
children  enter  the  world  with  their  lower  central  incisors  already 
cut,  sometimes  the  latter  do  not  make  their  appearance  until 
the  end  of  the  first  year  after  birth.  As  has  been  observed 
before,  the  eruption  is  completed  generally  at  the  end  of  the 
second  year  after  birth,  though,  frequently,  it  is  prolonged 
many  months  beyond  this  period.* 

It  would  be  an  interesting  point  to  determine  the  normal  in- 
tervals between  the  eruption  of  the  different  kinds  of  teeth, 
since,  from  the  longer  or  shorter  intervals,  an  approximate  con- 
clusion might  be  deduced  concerning  the  growth  of  the  jaw  in 
its  different  dimensions;  variations,  however,  in  this  respect  are 
presented  in  the  same  individual.  In  general,  it  may  be  said 
that  the  interval  between  the  completed  eruption  of  the  central 
and  the  lateral  incisors,  and  between  that  of  the  latter  and  the 
first  molars,  is  about  ten  or  twelve  weeks  for  each  kind  men- 
tioned, while  that  between  the  eruption  of  the  first  molars  and 
canine  teeth  is  prolonged  to  twenty  or  twenty-four  weeks ;  the 
second  molars  succeed  the  canine  teeth  after  a  similar  period. 
The  intervals  before  the  appearance  of  the  canine  teeth  and 
second  molars,  therefore,  are  about  twice  as  long  as  those  be- 
tween the  first  mentioned  kinds  of  teeth. 

In  regard  to  the  eruption  of  the  teeth  in  the  upper  and  lower 
jaw  respectively,  it  is  the  rule  that  the  lower  incisors  appear 

*  The  eruption  of  the  deciduous  teeth  usually  takes  place  at  about  the 
following  ages: 

Central  incisors, 7th  month. 

Lateral  incisors,     .....       9th      " 

First  molars, 12th      " 

Canines,  ......     18th       " 

Second  molars,       .         .  .         .     24th      " 

T.  B.  H. 


76 


ANATOMY    AND    PHYSIOLOGY. 


first,  and  generally  the  upper  ones  succeed  them  in  a  very  short 
time.     The  reverse  is  the  case,  frequently,  -with  the  molars. 

Second  Dentition. — The  eruption  of  the  first,  molars  ushers 
in  the  shedding  of  the  teeth.  They  appear  in  the  seventh  year 
and  genei'ally  in  the  upper  jaw  earlier  than  in  the  lower. 
Toward  the  end  of  the  second  year,  the  crowns  of  those  in  the 
upper  jaw  are  situated  high  up  in  the  maxillary  tuherosity,  and 
those  in  the  lower  jaw,  in  the  coronoid  process,  and  as  the  de- 
velopment of  the  jaws  progresses,  they  descend  towards  the 
dental  range.  The  alveoli  of  the  crowns  undergo  a  process  of 
gradual  resorption  in  the  vicinity  of  the  summits  of  the  latter, 
and   contemporaneously    with   this  process,  the  growth  of  the 

radical  portion  commences.  For 
^^''•"•*  some  time hefore  the  emergence 

of  the  first  molars,  the  margins 
of  their  alveoli  have  undergone 
a  considerable  amount  of  re- 
sorption, but  are  still  separated 
from  the  alveoli  of  the  second 
molars  by  partially  membran- 
ous septa  (Fig.  22).  Concur- 
rent with  the  emergence  of  the 
teeth,  the  alveoli  for  the  roots 
in  the  upper  jaw  form  three  broad,  cup-like  depressions,  sepa- 
rated from  one  another  by  projecting  partition-walls  or  septa. 
In  the  lower  jaw  are  found  two  similar  shallow,  flattened  de- 
pressions. Generally,  at  this  period  of  their  development,  the 
roots    present    remarkably    sharp    edges    and    broad     cavities. 


*  Fig.  22. — Eight  half  of  the  upper  jaw  of  a  child  between  five  and  six 
j'ears  of  age.  View  of  the  palatal  surface.  The  process  of  resorption  is 
seen  to  have  made  considerable  progress  upon  the  margins  of  the  coronal 
alveolus  of  the  first  permanent  molar  (near  a),  and  the  latter  communicates 
with  the  coronal  alveolus  of  the  second  permanent  molar.  The  three  de- 
pressions at  the  bottom  of  the  cavity  correspond  with  the  three  incompletely 
formed  roots  belonging  to  the  detached  tooth ;  (ft)  incisive  fissure  which 
is  met  with,  sometimes,  in  adults.  Upon  the  lingual  wall  of  the  alveolar 
process,  and  corresponding  to  the  localities  of  the  lateral  incisor  and  first 
molar  of  the  milk  set,  openings  are  visible  for  the  corresponding  permanent 
teeth,  produced  by  the  process  of  resorption.     Natural  size. 


SECOND    DENTITION.  77 

When  the  coronal  cusps  of  the  first  molars  have  reached  the 
level  of  those  of  the  deciduous  molars,  their  roots  are  scarcely 
more  than  a  few  millimetres  in  length.  The  subsequent  growth 
of  the  roots  in  length  and  of  the  jaws  in  depth  is  a  compara- 
tively rapid  process.  * 

The  shedding  of  the  teeth  involves  all  the  milk  teeth,  and 
commences  as  soon  as  the  crowns  of  the  permanent  teeth, 
through  reason  of  the  development  of  their  roots,  draw  near  to 
the  alveoli  of  the  milk  teeth.  A  series  of  phenomena  then  en- 
sues in  the  alveoli,  and  in  the  milk  teeth  themselves,  which  have 
been  embraced  under  the  general  term  resorption.-  This  process 
manifests  itself  by  a  loss  of  substance  wdiich  commences  in  the 
alveoli  of  the  milk  teeth,  then  usually  attacks  the  apices  of  their 
roots,  and  finally  the  entire  roots  and,  in  many  cases,  involves 
a  large  portion  of  the  crowns.  Generally  this  process  attacks 
the  milk  tooth  upon  the  side  towards  the  advancing  crown  of  the 
permanent  tooth,  though  frequently  it  commences  at  many 
points  simultaneously,  and  gives  rise  to  pitted  or  funnel-shaped 
depressions,  grooves,  or  irregular  facets,  looking  like  the  effects 
of  corrosion,  all  of  which  are  characterized  by  their  rough,  ex- 
posed surfaces  and  sharp  edges.  We  are  indebted  to  Tomes  for 
the  first  thorough  histological  investigation  and  correct  inter- 
pretation of  the  various  phenomena  presented  by  this  process  of 
resorption. 

If  we  examine  closely  a  portion  of  the  cement  of  the  root  of 
a  deciduous  tooth  which  has  been  affected  by  this  process,  we  find 
what  at  first  appears  to  be  a  simple  depression;  under  the  micro- 
scope, however,  this  is  found  to  be  made  up  of  a  number  of  smaller, 
cup-shaped  excavations,  which,  seen  from  above,  are  bounded  by 
sharp,  elevated  laminte  and,  upon  still  closer  examination,  dis- 
play, in  suitable  places,  a  network  of  projections  in  each  micro- 
scopic cavity.  The  bone-corpuscles,  together  with  the  interme- 
diate substance,  undergo  a  decomposition ;  first  of  all,  a  molec- 
ular cloudiness  occurs  in  their  immediate  vicinity,  and  also  in 
the  intercorpuscular  substance ;  the  radiating  bone-canaliculi 
become  indistinct,  disappear,  and  the  bone-corpuscles,  deprived 
of  their  radiating  canaliculi,  are  isolated  w^ithin  the  cavities 
which  become  more  clear  by  the  solution  of  the  substance  con- 


78  ANATOMY    AND    PHYSIOLOGY. 

tained  in  them,  and  in  which  the  network  of  delicate  projecting 
himincTG  gradually  disappears ;  the  walls  of  contiguous  cavities 
become  thinner,  and  finalljr  are  entirely  absorbed  (Atlas,  Fig. 
112),  As  the  same  process  is  repeated,  and  gives  rise  to  larger 
and  smaller  gi*oups  of  such  indentations  (Resorptionsalveolen), 
the  cement  substance  in  the  affected  localities  is  entirely  de- 
stroyed, so  that,  finally,  cross-sections  present  an  excavation  with 
an  irregularly  notched  boundary. 

The  same  process  also  takes  place  in  the  dentine  when  simi- 
lar indentations  are  produced  by  resorption  and  occasion  a 
roughness  of  the  surface.  Not  merely  those  portions  adjacent 
to  the  cement  are  attacked  by  this  process,  but  the  inner  por- 
tions also,  which  inclose  the  root  canal  (Atlas,  Fig.  111). 

Resorption  of  the  milk  tooth  is  frequently  accompanied  by  a 
new  formation  of  osseous  substance,  a  phenomenon  of  frequent 
occurrence  with  new  formations,  that  is  to  say,  involution  by 
the  side  of  evolution. 

The  new  formation  and  resorption  can  readily  be  studied  in 
that  portion  of  the  cement  where  no  rows,  or,  still  better,  where 
a  single  row  of  bone-corpuscles  occurs.  In  addition  to  the  in- 
dentations produced  by  resorption  already  described,  which  quite 
frequently  are  coated  with  the  remains  of  the  organic  basis- 
substance,  cross-sections  also  present  clear,  hemispherical, 
sharply  defined  masses  imbedded  in  the  cement ;  these  are 
either  separate  or  grouped  together,  and  gradually  extend  be- 
yond the  boundary  of  the  cement  even  into  the  dentine,  and  not 
unfrequently  assume  a  radiating  arrangement. 

The  central  portion  of  these  masses  contains  irregular  cavities, 
which  denote  the  points  where  the  process  of  resorption  com- 
menced. The  osseous  substance,  which  encroaches  considerably 
upon  the  dentine,  is  always  sharply  defined  ;  the  corpuscles,  like- 
wise, either  singly  or  in  groups,  are  inclosed  by  a  bright  cap- 
sular layer  (Atlas,  Fig.  110).  Such  corpuscles  resemble  young, 
immature  bone-corpuscles,  the  canaliculi  of  which  have  not  yet 
formed  their  mutual  connections.  Not  unfrequently  the  cor- 
puscles are  irregularly  formed,  elongated  ;  present  several  long 
offshoots,  or  are  large,  without  any  definite  form,  as  if  resulting 
from  a  blending  together  of  separate  ones.     As  they  increase  in 


SECOND    DENTITION. 


79 


volume,  and  lose  their  proper  characteristics,  they  assume  an 
appearance  like  that  of  gaps,  resulting  from  interstitial  resorp- 
tion, and  filled  with  amorphous  calcareous  salts,  and  all  the  more 
so  from  the  fact  that  very  decided  evidences  of  resorption  are 
found  in  their  vicinity. 

The  newly-formed  osseous  substance  is  immediately  subjected 
to  a  peripheral  resorption,  while  the  capsule  of  the  corpuscles 
thickens,  and  the  latter,  finally,  are  destroyed.  The  cloudy, 
granular,  discolored  substance  contains  a  greater  or  less  amount 
of  fat,  which  is  the  remains  of  the  disintegrated  tissue. 

When  the  resorption  of  the  milk  teeth  has  progressed  so  far 
that  a  small  portion  only  of  the  crown  remains,  the  enamel, 
likewise,  becomes  eroded 
and  resorption  indenta- 
tions  make  their  appear- 
ance in  it  also  (Fig.  23). 
Tomes  has  also  observed 
the  development  of  osse- 
ous substance  upon  the 
outside  of  the  enamel. 

If  a  milk  tooth,  in 
which  resorption  has  made 
some  progress,  be  sepa- 
rated from  the  jaw,  a  loose,  spongy  substance  remains  adherent 
to  it,  which  a  long  time  ago,  was  claimed  by  Laforgue  and 
Bourdet  to  be  the  absorbent  organs.  It  was  supposed  that  the 
latter  secreted  a  fluid  capable  of  dissolving  the  substances  of 
the  tooth.  Tomes  made  a  microscopic  examination  of  this  pa- 
pillary organ,  and  states  that  its  surface  is  made  up  of  peculiar 
multiform  cells,  each  one  being  composed  of  several  smaller 
cells,  the  number  varving  from  two  or  three  to  as  many  as  four- 
teen or  fifteen.  Some  few  deviating  forms  bear  a  strong  re- 
semblance to  the  cells,  described  by  Kblliker  as  myeloid  cells. 


*  Tio.  28. — Kesorption  indentations  which  penetrate  from  the  surface  of 
the  enamel  toward  the  deeper  layers,  resembling,  in  the  manner  in  which 
they  are  grouped  together,  glandular  lobes,  and  tilled  with  a  cloudy,  gran- 
ular mass.  The  contiguous  portion  of  the  enamel  is  in  its  normal  condition. 
Magnified  250  diameters. 


80  ANATOMY    AND    PHYSIOLOGY. 

Each  hemispherical  depression  of  the  absorbent  surface  of  tlie 
tooth  is  occupied  by  such  a  cell  as  has  been  described.  Beneath 
the  surface  of  the  papillre,  there  are  commonly  found  nucleated 
cells  and  free  nuclei,  and,  in  the  deepest  layers,  a  fibrous  tissue 
in  the  process  of  development. 

According  to  my  experience  upon  this  point,  which  indeed  is 
limited,  these  compound  cells  (Tomes)  are  not  of  constant  occur- 
rence; I  have  not  been  able  to  discover  them  in  some  eases,  but 
have  perceived  merely  aggregations  of  single  cells  of  connective 
tissue.  Hohl  has  succeeded  only  in  one  case  in  discovering  a 
few  gigantic  cells,  and  he  is  of  the  opinion  that  the  large  cells 
described  by  Tomes  are  nothing  but  nests  of  cells  with  connective- 
tissue  capsules.  How  the  destruction  of  the  hard  substances  of 
the  tooth  is  accomplished  by  these  cells,  we  have  no  clear  con- 
ception ;  to  me  it  seems  more  probable  that  a  fluid  is  secreted 
by  the  cells,  which  dissolves  the  hard  substance,  than  the  theory, 
held  by  some,  that  these  cells 'are  of  a  parasitic  nature,  that  is 
to  say,  that  the  dental  substances  are  eaten  up,  as  it  were,  since 
the  cells  absorb  the  latter.  Possibly  amoeboid  movements  may 
be  the  occasion  of  the  wasting  of  the  tissues. 

The  so-called  absorbent  organ,  however,  induces  also  an  os- 
seous formation,  already  described,  since  the  cement,  notwith- 
standing its  partial  resorption,  evinces,  on  the  other  hand,  a  pro- 
ductive activity  which  results  in  the  development  of  osseous  sub- 
stance within  the  dentine  and  upon  the  exterior  of  the  enamel. 
When  the  cells  of  the  milk  teeth  are  absorbed,  those  of  the  per- 
manent teeth  are  completed.* 

*  The  organ  of  resorption  probably  is  developed  from  the  connect!  \'e  tissue 
of  the  root-tnembrane  of  the  milk  tooth,  and  from  the  medullary  matter  of 
the  adjacent  osseous  tissue,  and  is,  essentially,  a  granulation  tissue,  similar 
to  that  which  we  find  in  many  inflammatory  affections  of  the  bone,  or  in 
tumors  which  are  developed  in  the  osseous  substance.  We  also  find,  on  the 
one  hand,  upon  the  periphery  of  sarcoma,  cancer,  &c.,  a  resorption  of  the 
contiguous  bone,  and  on  the  other  hand,  frequenth^  a  growth  of  trabecular 
osseous  tissue.  Therefore,  during  the  shedding  of  the  teeth,  an  hyperajmic 
condition  occurs  in  the  root-membrane  and  the  medullary  matter  of  the 
bone  adjacent  to  it;  the  activity  of  the  cells  becomes  augmented,  in  conse- 
quence of  which  the  whole  process  of  nutrition  is  carried  on  more  rapidly 
than  under  ordinary  conditions  ;  the  j'oung,  more  vigorous  cells  supplant 
the  older,  enfeebled  ones.     In  the  organism  of  youth,  also,  we  find  that  in  the 


SECOND    DENTITION. 


81 


When  the  resorption  of  the  milk  tooth  is  completed  with  the 
exception  of  a  certain  portion,  variable  according  to  local  cir- 
cumstances, its  alveolus  has,  for  the  most  part,  disappeared,  and 
that  of  the  permanent  tooth  occupies  its  place.  This,  however, 
is  not  always  the  case,  particularly  when  the  milk  teeth  are  shed 
prematurely,  or  the  permanent  teeth  occupy  anomalous  posi- 
tions, and  in  such  cases  there  remains  upon  the  summit  of  the 
alveolar  process  an  oval  or  circular  channel,  in  the  centre  of 
which  is  found  a  conical  osseous  papilla,  which  is  to  be  consid- 
ered as  the  remains  of  the  bony  substance  which,  in  its  growth, 
occupied  the  pulp-cavity  (Atlas,  Fig.  3). 


Fig.  24.= 


growth  of  bone,  there  occurs  upon  one  side  resorption,  and  upon  the  other 
pri)dLicti(jn,  as  for  example,  in  the  flat  bones  of  the  skull,  resorption  occurs 
on  the  inner  surface,  growth  on  the  outer  surface  which  is  in  relation  with 
the  galea  aponeurotica.  Again,  in  the  tibia,  resorption  takes  place  in  the 
central  medullarj^  canal,  and  growth  upon  the  periosteum  and  epiphyses. 
These  processes,  too,  explain  the  increase  in  size  of  the  cranial  cavity  and 
central  medullary  canal  of  the  tibia. 

*  Fig.  24. — Set  of  milk  teeth  with  the  corresponding  permanent  teeth 
still  imbedded  within  the  jaw.  The  tirst  permanent  molars  («)  have  already 
emerged  from  the  jaw  both  above  and  below,  so  that  the  second  dentition 
has  commenced.  Profile  view  from  the  right  side.  The  somewhat  inclined 
crowns  of  both  permanent  incisors  are  visible  behind  the  extremities  of  the 
roots  of  the  milk  incisors.     The  crown  of  the  upper  canine  tooth  (b)  presents 

6 


82 


ANATOMY    AND    PHYSIOLOGY. 


Fig.  2.1  * 


Before  passing  to  the  consideration  of  the  separate  teeth,  it  is 

to  be  premised  that  the  permanent 
teeth  in  the  upper  jaw  are  arranged 
somewhat  differently  from  those  in 
the  under  jaw,  in  their  rehitions  to 
the  milk  teeth,  and  also  that  the  dif- 
ferent kinds  of  teeth  present  varia- 
tions in  this  respect  (Fig.  24). 

Commonly,  toward  the  end  of 
the  fourth  year,  small,  barely  per- 
ceptible apertures  appear  in  the  under  jaw,  behind  the  central 
milk  incisors,  and  adjacent  to  the  lingual  alveolar  margin  ;  these 
gradually  enlarge  so  as  to  admit  the  incisive  edges  of  the  per- 
manent central  incisors  between  their  smooth  borders.  In  the 
meantime,  similar  apertures  become  visible  behind  the  lateral 
incisors.  When  the  edges  of  the  permanent  central  incisors 
have  reached  the  level  of  the  lingual  alveolar  margin,  the  edges 
of  the  lateral  incisors  are  still  some  millimetres  deeper,  and  are 
inclined  somewhat  toward  the  medium  line  and  backwards  (Fig. 
25).  Since  the  total  breadth  of  the  crowns  of  the  two  perma- 
nent incisors  is  greater  than  that  of  the  corresponding  milk 


a  marked  inclination,  and  is  situated  high  up  in  its  alveolus;  the  lower  per- 
manent canine  (c)  likewise  occupies  a  deep  position.  The  crowns  of  the  per- 
manent bicuspids  are  grasped  by  the  diverging  roots  of  the  milk  molars. 
The  mental  foramen  (rf)  is  seen  between  the  first  and  second  milk  teeth. 
The  crowns  of  the  second  permanent  molars,  inclosed  within  their  alveoli, 
are  imbedded  in  the  maxillary  tuberosity  and  coronoid  process.  Natural 
size. 

*  Fig.  25. — Front  view  of  the  lower  jaw  at  the  commencement  of  the 
process  of  shedding  the  teeth,  showing  the  relative  positions  of  the  anterior 
milk  and  permanent  teeth.  On  the  left  side,  the  two  milk  incisors  and 
canine  were  left  in  their  natural  positions,  with  reference  to  the  permanent 
teeth  lying  posteriorly  and  inferioriy.  The  process  of  resorption  is  i'arther 
advanced  in  the  extremit}'  of  the  root  of  the  central  incisor,  than  it  is  in 
that  of  the  lateral.  On  the  right  side,  the  milk  teeth  have  been  removed  ; 
the  permanent  teeth  lie  within  their  alveoli  in  an  inclined  plane.  The 
notched  edges  of  the  permanent  central  incisors  have  reached  the  alveolar 
margin,  those  of  the  laterals  being  situated  about  two  millimetres  lower 
down  ;  the  latter  teeth,  also,  are  inclined  somewhat  toward  the  median  line, 
although  to  a  less  degree  than  the  conical  crowns  which  are  deeply  situated 
and  inclosed  within  their  alveoli.     Natural  size. 


SECOND    DENTITION.  83 

teeth,  the  eruption  of  the  former,  side  by  side,  would  be  impos- 
sible, so  long  indeed  as  the  milk  canine  teeth  remained  in  situ, 
if  provision  were  not  made  to  secure  sufficient  space,  as  will  be 
shown  farther  on  in  connection  with  the  subject  of  the  growth 
of  the  jaw. 

Similar  phenomena  attend  the  cutting  of  the  permanent  inci- 
sors of  the  upper  jaw,  with  the 
exception  that,  in  consequence 
of  the  greater  difference  in  size 
between  the  milk  and  permanent 
incisors,  the  upper  permanent 
lateral,  before  it  is  cut,  has  a 
still  greater  inclination  than  the  , 

under   one   toward   the    median  I  ^^  i       llJ    Njff 

line    and    posteriorly.      Hence 
still   more   space   must   be  pro- 
vided in  the  upper  jaw  than  in  the  lower,  for  the  eruption  of 
the  permanent  incisors  (Fig.  26). 

The  first  bicuspids  generally  are  the  next  to  take  their  places 
in  the  dental  range  ;  it  is  not  an  infrequent  occurrence,  however, 
for  their  eruption  to  precede  that  of  the  lateral  incisors ;  the 
second  bicuspids  usually  succeed  the  canine  teeth.  The  alveoli 
of  the  permanent  bicuspids  of  the  lower  jaw  are  situated  between 
the  anterior  and  posterior  root  of  each  milk  molar.  As  the  in- 
closed crowns  of  the  permanent  bicuspids,  taken  together,  occupy 
less  space  than  those  of  the  milk  molars  with  their  diverging 

*  Fia.  26. — Pront  view  of  the  upper  jaw,  of  a  child  seven  years  of  age, 
presenting  an  abnormal  dentition.  The  central  incisors  have  descended  to 
the  level  of  the  dental  range ;  the  edges  of  the  lateral  incisors  are  situated 
seven  millimetres  higher  up;  the  latter  also  are  still  inclined  somewhat 
toward  the  median  line  and  backward,  and  consequently  have  not  yet  com- 
pleted their  slight  rotation.  The  crowns  and  the  already  completed  roots  of  the 
permanent  canine  teeth  are  situated  high  up  in  the  anterior  segment  of  the 
septum  between  the  nasal  and  maxillary  cavities,  and  are  inclined  toward 
the  median  line.  The  extremities  of  the  roots  of  the  milk  canines  («,  a),  the 
crowns  of  which  are  afiFected  with  caries,  are  already  absorbed.  The  first 
permanent  bicuspid  on  the  left  side  {b)  has  descended  nearly  to  the  level  of 
the  dental  range,  while  the  first  milk  molar  on  the  right  side  (c)  is  not  yet 
shed,  and  retains,  between  its  roots,  the  first  permanent  bicuspid,  the  radical 
portion  of  which  is  developed  to  a  slight  degree.     Natural  size. 


8-i  ANATOMY    AND    PHYSIOLOGY. 

roots,  space  is  reserved  anterior!}',  after  the  eruption  of  the  first 
permanent  bicuspids,  for  the  permanent  canine  teeth.  As  the 
second  lower  milk  molar  is  considerably  larger  than  the  first, 
while  the  second  lower  permanent  bicuspid  is  of  nearly  equal 
size  Avitk  the  first,  the  roots  of  tlie  first  lower  milk  molar  undergo 
a  more  notable  resorption.  In  consequence  of  the  fact  that  the 
permanent  bicuspids  are  embraced  by  the  roots  of  the  milk 
molars,  as  if  by  forceps,  it  is  necessary  to  exercise  especial  care 
in  connection  with  the  extraction  of  the  latter,  for  if  it  becomes 
necessary  to  extract  the  milk  molar  on  account  of  its  unsound- 
ness before  resorption  of  its  roots  has  commenced,  the  crown  of 
the  permanent  molar  will  necessarily  be  extracted  at  the  same 
time,  because  it  is  so  tightly  embraced  by  the  roots  of  the  milk 
tooth  (Atlas,  Fig.  15). 

The  permanent  canine  teeth  remain  w-ithin  their  temporary 
alveoli  very  deeply  imbedded  in  the  under  jaw,  with  their  long 
diameters  inclined  towards  the  median  line,  until  the  eruption 
of  the  perfectly  developed  permanent  incisors  is  completed,  and 
the  first  permanent  molars  with  their  roots  are  entirely  formed; 
the  milk  molars,  however,  have  not  yet  been  shed.  When,  in 
consequence  of  continued  resorption  of  the  root,  the  milk  canine 
tooth  becomes  so  loose  that  it  falls  out,  the  permanent  canine 
tooth  necessarily  is  slightly  tilted  laterall}-  on  its  long  axis,  be- 
comes more  upright,  and  enters  directly  into  the  space  left  vacant 
by  the  lower  milk  canine.  Since,  however,  the  latter  space  is  too 
small,  the  space  reserved  after  the  succession  of  the  first  bicuspid 
now  comes  into  play.  The  position  of  the  upper  canine  teeth 
in  their  temporary  alveoli,  is  analogous,  that  is  to  say,  their 
long  diameters  are  inclined  somewhat  toward  the  median  line, 
and  the  developing  roots,  together  with  the  large  rounded  crowns, 
are  implanted  in  the  osseous  wedge  (Knochenzwickel)  between 
the  facial  wall  of  the  upper  jaw,  and  the  septum  of  the  nasal 
cavity  and  antrum  of  Highmore.  The  canines,  when  inclosed 
in  their  bony  capsules,  occup}^  the  highest  position  of  all  the 
teeth  in  the  upper  jaw,  and  their  crowns  experience,  in  their  de- 
scent, a  slight  lateral  tilting,  by  means  of  which  their  crowns 
acquire  a  more  perpendicular  direction. 

AVhen  the  first  molars  have  emerged  completely,  the  prepara- 


SECOND    DENTITION.  85 

tions  for  the  eruption  of  the  second  molars  are  completed.  The 
jaws  have  increased  in  length  in  their  posterior  segments,  and 
oval  apertures  are  perceptible  upon  the  summit  of  the  alveolar 
process  behind  the  first  molars.  In  the  lower  jaw,  these  apertures 
are  at  the  base  of  the  coronoid  processes  and,  in  the  upper  jaw, 
in  the  upper  part  and  to  the  outside  of  the  tuberosities.  From 
the  posterior  margins  of  these  apertureg  extends  a  more  or  less 
distinct,  shallow,  short,  narrow,  bony  groove,  which  is  known  as 
the  posterior  dental  groove.  About  the  end  of  the  eighth  year 
the  apertures  enlarge,  and  the  coronal  cusps  of  the  second  molars 
may  be  seen  at  the  bottom  of  them.  If  the  facial  wall  of  the 
jaw  and  the  corresponding  segment  of  the  rounded  alveolus  be 
removed,  the  lateral  portion  of  the  incomplete  crown  will  be  ex- 
posed. The  subsequent  phenomena  attending  the  growth  of 
these  teeth  are  similar  to  those  attending  the  development  of 
the  first  molars.  The  process,  however,  is  slower,  their  eruption 
not  being  completed  until  the  twelfth  or  thirteenth  year,  making 
an  interval  of  five  to  six  years  between  the  eruption  of  the  first 
and  second  molars. 

The  above-mentioned  posterior  dental  groove,  ascending  from 
the  base  of  the  coronoid  process,  and  bending  upwards  like  a 
bow  over  the  tuberosity,  bears  a  striking  resemblance  to  the 
dentnl  groove  in  the  jaw  of  a  three  months'  foetus.  It  is  cov- 
ered with  a  delicate  mucous  membrane.  At  a  later  period  there 
appears  in  the  posterior  segment  a  small  crypt  (Alveole)  about 
the  size  of  a  millet-seed,  which  is  intended  for  the  tliird  molar, 
or  wisdom  tooth.  A  spicula  of  bone,  the  unabsorbed  remains 
of  the  outer  extremity  of  the  alveolus,  frequently  is  found, 
at  this  period,  attached  to  the  outer  edge  of  the  aperture  pro- 
duced by  resorption,  and  continues  to  obstruct  the  entrance  to 
the  alveolus  of  the  second  lower  molar.  Concurrent  Avith  the 
expansion  of  the  crypt-like  depression  for  the  Avisdom  tooth,  an 
osseous  lamina  is  developed  behind  the  alveolus  of  the  second 
molar,  the  alveolar  septum,  which  gradually  becomes  more 
prominent.  About  the  twelfth  year  the  alveolus  of  the  wisdom 
tooth,  shaped  like  a  shallow  dish,  attains  the  size  of  a  small 
lentil,  but  still  is  situated  high  up  in  the  tuberosity  of  the  upper, 
and  in  the  base  of  the  ascending  coronoid  process  of  the  lower 
jaw.     As  the  growth  of  the  posterior  segments  of  the  jaws  is 


86  ANATOMY    AND    PHYSIOLOGY. 

advanced  considerablj,  Avliicli  process  takes  place  much  more 
slowly  than  in  the  earlier  years,  the  alveoli  of  the  wisdom  teeth 
begin  to  advance,  and  finally  reach  the  level  of  the  dental  range. 
In  the  meantime  the  alveoli  of  their  crowns  have  become  deeper 
and  wider,  and  the  coronal  cusps  become  perceptible  in  the 
apertures  upon  the  alveolar  processes  and  gradually  become 
larger  by  resorption.  Their  eruption  occurs,  as  is  well  known, 
a  few  years  before  or  after  the  twentieth  year  of  life. 

The  opinion  is  entertained  by  some  that  the  germ  of  the 
wisdom  tooth  is  derived  from  a  process  of  that  of  the  second 
molar.  But  the  facts  which  have  been  mentioned  that,  as  the 
growth  of  the  posterior  segment  of  the  jaw  advances,  the  mucous 
membrane  becomes  extended  over  the  posterior  dental  groove, 
and  that  the  development  of  the  alveolus  of  the  wisdom  tooth 
occurs  within  the  latter,  are  much  more  in  favor  of  the  view 
that  the  germ  of  the  wisdom  tooth,  like  those  of  the  other  teeth, 
is  the  product  of  the, formation  of  a  sac  and  papillae  directly 
from  the  epithelium  and  corium  of  the  mucous  membrane.  I 
have  been  unable  to  obtain  histological  evidence  in  proof  of  the 
latter  theory,  yet  I  consider  it,  nevertheless,  as  probable.  Ac- 
cording to  the  recent  statements  of  Kollmann,*  the  enamel 
germs  of  the  second  and  third  molars  are  not  developed  directly 
from  the  epithelium  of  the  oval  cavit}',  but  from  the  enamel  germ 
of. the  first  molar. f 

*  Op.  cit. 

f  The  second  dentition  sometimes  does  not  commence  until  the  second  or 
third  decade.  D.  Fricke,  of  Liineburg  (Deutsche  Vierteljahressch.  f.  Z., 
1869),  saw  two  girls,  one  eighteen  and  the  other  sixteen  years  old,  both  of 
whom  still  retained  all  the  twenty  milk  teeth  which  were  worn  away  very 
much. 

[The  permanent  teeth  usualh'  appear  at  about  the  following  ages,  and  in 
the  following  order : 

First  molars,         ^.         .         .         .       6th  to    7th  year. 


Central  incisors,    . 
Lateral  incisors,     . 
First  bicuspids. 
Second  bicuspids,   . 
Canine, . 
Second  molars, 
Third  molars, 


7th  to  8th 
8th  to  9th 
9th  to  10th 
10th  to  11th 
11th  to  12th 
12lh  to  14th 
17th  to  21st 


T.  B.  H.] 


THIRD    DENTITION.  87 

Third  Dentition. — The  possibility  of  the  occurrence  of  a 
third  dentition  is  doubted,  and  even  openly  denied  by  many. 
Its  opponents  assert  that  cases  of  presumed  third  dentition  are 
merely  instances  in  which  the  teeth  have  not  emerged,  but  have 
remained  imbedded  within  the  jaw  until  the  occurrence  of  senile 
resorption  of  the  alveolar  processes.  Deceptions  may  easily  occur 
in  regard  to  them,  particularly  among  the  ignorant,  as  will  be 
evident  from  reference  to  the  section  upon  the  retention  of 
teeth.  On  the  other  hand,  however,  we  ought  not  to  persist  in 
the  denial  of  the  occurrence  of  a  third  dentition,  on  the  ground 
that  it  is  contrary  to  the  current  physiological  doctrines. 

The  writers  of  former  times,*  Aristotle,  Eustachius,  and  Al- 
binus,  mention  a  repeated  renewal  of  the  teeth.  In  recent  times, 
Fauchard,  Bourdet,  J.  Hunter  (the  latter  observed  a  third  set 
of  teeth  in  both  jaws).  Van  Swieten,  Haller,  collected  several 
such  cases  from  different  writers.  Hufeland  describes  a  case 
which  came  to  his  knowledge.  In  the  one  hundred  and  six- 
teenth year  of  life,  new  teeth  were  said  to  have  made  their  ap- 
pearance ;  six  months  after  the  loss  of  these,  new  molars  appeared 
in  each  jaw.  Serres  observed  two  cases  in  the  Hopital  de  la 
Pitie ;  one  of  a  man  thirty-five  years  old,  whose  two  lower  cen- 
tral incisors  fell  out,  and  were  replaced  after  a  few  months  ;  the 
other  of  a  man  seventy-six  years  old,  who,  during  convalescence 
from  a  bilious  fever,  experienced  pain  and  swelling  in  the  gum 
of  the  under  jaw,  which  disappeared  on  the  eruption  of  a  tooth 
with  several  eminences  in  the  place  of  the  second  molar  on  the 
left  side.  The  margins  of  the  alveoli  had  not  yet  disappeared  in 
this  old  man. 

C  A.  Harrisf  has  no  doubt  that  a  third  dentition  does  occur 
in  extremely  rare  cases,  and  instances  a  number  of  examples 
where  individuals,  who  for  a  long  time  had  been  toothless,  ac- 
quired several  teeth,  or  even  an  entire  set,  in  extreme  old  age. 
According  to  the  authority  of  Dr.  Bisset,  of  Knayton,  twelve 
molars  made  their  appearance  in  a  woman  ninety-eight  years 
old.     Harris  himself  observed  two  cases,  the  second  of  which  is 

*  Carabelli's  and  Linderer's  Geschichte  der  Zahnheilkunde. 
f  Principles  and  Practice  of  Dental  Surgery.     Phil.,  1850. 


88  ANATOMY    AND    PHYSIOLOGY. 

■\vortliy  of  note,  uhcre  four  central  incisors  made  their  appear- 
ance, one  after  the  other,  on  one  side  of  the  upper  jaw.  Such 
teeth,  he  remarks,  seldom  lie  in  alveoli,  and  have  either  no  roots 
or  stunted  ones.  He  thinks  it  not  improbable  that  duplicatures 
of  the  mucous  membrane  occur  during  the  healing  process  which 
ensues  after  the  extraction  of  one  or  more  teeth.  M.  Carre 
relates  the  case  of  a  woman  eighty-five  years  old,  who  cut  a  left 
upper  canine,  and  a  few  months  later,  a  left  lateral  incisor  and 
first  bicuspid  on  tiie  right  side  in  each  jaAv.'''  Heider  reported 
a  case  of  multiple  formation  of  a  dwarfish  canine  tooth  in  a  wo- 
man not  very  old.f 

If  we  admit  the  occurrence  of  a  third  dentition  in  very  rare 
cases,  it  is  by  no  means  necessary  to  assume,  as  Harris  thinks,  the 
origin  of  a  new  dental  germ  after  the  permanent  teeth  have  been 
detached,  since  it  cannot  really  be  denied  that  germs  may  lie 
dormant  for  many  years  in  the  animal  organism,  until  they  are 
subjected  to  favorable  conditions  which  enable  them  to  develop. 
The  possibility  that  during  a  long  series  of  years  a  germ  may 
remain  dormant  in  the  lateral  folds  of  the  enamel  gum,  cannot 
be  rejected  on  theoretical  grounds.  Kollmann  even  asserts  that 
the  germs  for  such  a  late  dentition  have  their  origin  in  the  ear- 
liest years  of  childhood.  The  fact  that  the  crowns  only  are 
formed  while  the  roots  are  stunted  is  clearly  due  to  the  small 
depth  of  the  jaws  in  old  age. 

Groavtii  of  the  Jaws. — Ossification  of  the  up2:)er  jaw  com- 
mences at  a  very  eaidy  period.  SappeyJ  describes  five  centres 
of  ossification.  As  the  ossification  advances,  sutures  make  their 
appearance,  which  directly  disappear  again.  The  most  con- 
spicuous suture,  easily  distinguished  both  in  the  foetus  and  in 
the  first  years  after  birth,  and  even  later,  is  the  sutura  incisiva, 
which  extends  from  the  foramen  incisivum  across  to  the  septum, 
between  the  alveoli  of  the  lateral  incisor  and  canine.  In  rare 
cases  it  is  also  continued  upon  the  facial  wall  of  the  upper  jaw, 
between  the  above  teeth,  and  can  be  traced  into  the  nasal  pro- 
cess as  far  as  the  inner  portion  of  the  inferior  margin   of  the 

*  Med.  and  Surg.  Reporter,  1860. 
t   Vide  Anomalies  of  Formation. 
X  Anatomic  Descriptive,  2d  ed. 


GROWTH    OP    THE    JAWS.  89 

ovbit.  The  alveolar  portion  of  the  upper  jaw  is  divided  by  it 
into  a  smaller  anterior  segment,  which  includes  the  sockets  of 
both  incisors,  and  a  larger  posterior  segment,  which  contains 
the  remaining  sockets.  In  such  cases  its  analogy  with  the  os 
incisivum  of  mammals  is  evident.  The  deformity  known  as 
wolf's  jaw  denotes  a  persisting  fissure  between  the  intermaxil- 
lary bone  and  the  rest  of  the  alveolar  process.  In  luire-lip  these 
bones  are  united,  but  the  fissure  of  the  upper  lip  persists,  corres- 
ponding in  its  position  to  that  of  the  junction  of  the  bones.  If 
the  two  upper  jaws  are  not  united  at  the  palatal  suture,  the  de- 
formity known  as  cleft  palate  results.  These  malformations 
are  considered  to  be  the  results  of  arrest  of  development,  the 
cause  of  which  is  unknown. 

The  lower  jaw  is  formed  very  soon  after  the  collar-bone.  Ac- 
cording to  Sappey  (op.  cit.),  it  has  two  centres  of  ossification, 
which  make  their  appearance  about  the  thirty-fifth  day.  In  the 
foetus,  the  lower  jaw  is  divided  into  two  halves,  which  are  not 
wholly  united  until  some  time  in  the  course  of  the  first  year  after 
birth.  With  a  deformity  of  a  median  fissure  of  the  lower  lip,  a 
persistence  of  the  median  separation  of  the  lower  jaw  is  observed 
only  in  a  slight  degree  or  not  at  all. 

The  direction  of  the  groivth  of  the  under  jaw  may  be  ascer- 
tained in  part  from  the  direction  of  the  rays  of  bone.  The 
latter  may  be  seen  in  an  embryo,  extending  along  the  facial 
wall  from  the  head  of  the  articulating  process,  which,  as  yet, 
projects  scarcel}''  above  the  level  of  the  alveolar  border,  and  in 
front  of  the  margin  of  the  ascend inir  ramus,  in  horizontal  and 
somewhat  oblique  directions  towards  the  anterior  segment  of 
the  maxillary  arch ;  the  latter  are  joined  by  those  descending 
from  the  coronoid  process  which,  as  yet,  is  but  slightlj^  devel- 
oped. The  first-mentioned  rays  become  closely  compacted,  es- 
pecially in  the  vicinity  of  the  lower  border  of  the  jaw,  which 
thereby  increases  in  thickness.  The  inferior  dental  canal  pri- 
marily is  open  above  like  a  groove.  The  growth  of  the  lower 
jaw  is  most  conspicuous  upon  its  facial  wall  and  inferior  border. 
The  radiation  of  the  bone  is  not  distinctly  marked  on  its  lingual 
surface,  where  are  formed  instead  imbricated  lamelliTe  or  delicate 
networks   of  trabeculne.      Another  centre   of   ossific   radiation 


90  ANATOMY    AND    PHYSIOLOGY. 

daring  embryonic  life,  which  easily  escapes  observatioTi,  is 
beneath  the  mental  foramen.  Here  the  osseous  trabecuhe  are 
arranged  in  a  crescentic  form  around  the  inferior  margin  of  the 
foramen.  A  similar  radiation,  with  the  convexity  of  the  cres- 
cent turned  downwards,  may  be  seen  about  the  infraorbital  for- 
amen in  the  upper  jaw. 

Towards  the  end  of  the  third,  and  the  beginning  of  the  fourth 
month  after  birth,  the  articular  process  of  the  under  jaw  in- 
creases considerably  in  length,  and  the  formation  of  the  neck 
portion  takes  place.  By  a  corresponding  growth  of  the  cor- 
onoid  process,  the  saddle-like  concavity  of  the  sigmoid  notch 
becomes  more  distinctly  marked.  At  about  this  period,  a  third 
system  of  osseous  rays  is  met  with,  Avhich  at  a  later  period 
becomes  more  apparent,  and  extends  downwards  from  the  head 
of  the  condyle  to  the  obtuse  angle  of  the  under  jaw. 

At  birth,  the  lower  jaw  generally  is  still  separated  into  its 
two  halves.  The  facial  surface  of  the  future  symphysis  presents 
a  triangular,  fibro-cartilaginous  portion,  in  which  several  ossiiic 
centres  appear  during  the  first  months  after  birth.  Coincident 
with  the  latter  occurs  the  union  of  the  two  halves,  together 
with  the  formation  of  the  mental  process ;  the  former  takes 
place  from  below  upwards  and  is  completed  at  the  period  of 
the  eruption  of  the  central  incisors. 

At  birth,  the  angle  of  the  lower  jaw  presents  only  a  slight 
bend.  Upon  the  convexity  of  this  curve  the  osseous  substance 
is  deposited  subsequently  in  such  a  manner  that  the  vertex  of 
the  angle  gradually  becomes  more  pointed  (during  a  year  or 
year  and  a  half).  The  angle  formed  by  the  junction  of  the  hor- 
izontal and  ascending  rami  changes  but  little  during  this  time, 
but  in  the  subsequent  years  it  gradually  becomes  smaller  by  the 
deposition  of  bone  in  increasing  proportion  from  the  head  of 
the  condyle  towards  the  vertex  of  the  angle,  while  the  ascend- 
ing branch,  at  the  same  time,  gradually  increases  in  length. 

Previous  to  the  eruption  of  the  second  milk  molar,  the  growth 
of  the  posterior  segment  in  length  makes  considerable  progress. 
When  the  growth  necessary  for  the  milk  teeth  is  completed,  a 
delicate,  porous,  osteophyte-like  osseous  layer  is  observed  upon 
the  posterior  segment  of  the  inferior  maxillary  arch,  and  also 


GROWTH    OF    THE    JAWS.  91 

upon  the  tuberosity  of  the  upper  jaw.  The  growth  in  tliick- 
ness  takes  phice  principally  upon  the  inferior  border  of  the 
lower  jaw,  that  in  height  is  displayed  in  the  fan-shaped  ossific 
radiation  in  the  alveoli,  and  likewise  in  their  ascending  septa. 
The  spongy  substance  of  the  bone  between  the  alveoli  and  the 
maxillary  Avail  is  not  developed  at  first,  and  the  latter  lie  in 
juxtaposition  until  the  growth  of  the  bone  in  thickness  is  con- 
siderably advanced,  when  the  spongy  substance  makes  its  ap- 
pearance. In  the  first  and  second  years  after  birth,  the  exter- 
nal and  internal  oblique  lines,  together  with  the  spina  ment.  int., 
&c.,  are  rendered  more  prominent  by  means  of  increased  mus- 
cular action. 

Changes  in  the  Jaws  during  the  Second  Dentition. — Hunter* 
was  the  first  to  assert  that  in  the  portions  of  the  jaws  in  which 
the  milk  teeth  are  placed  growth  ceases  after  the  completion  of 
the  first  dentition.  Foxf  agreed  with  him  substantially.  They 
reached  this  conclusion  by  measurements  of  macerated  lower 
jaws.  Delabarre,J  on  the  other  hand,  endeavored  by  means  of 
clinical  observations  to  establish  the  fact  of  the  growth  of  the 
bone  in  length  after  the  first  dentition.  He  asserts  that,  at  the 
age  of  five  to  six  years,  the  milk  teeth  separate  from  each  other, 
and  says,  that  those  people  with  whom  this  does  not  occur  are 
liable  to  have  an  irregular  second  dentition.  Fox  had  recog- 
nized this  occurrence  before  Delabarre,  but  did  not  give  to  it 
the  same  significance,  for  he  states,  "the  anterior  portion  of  the 
jaw  undergoes  scarcely  more  than  an  alteration  in  form  ;  it 
adapts  itself  to  the  permanent  teeth  there  situated,  and  scarcely 
receives  any  increase  in  size."  Th.  Bell§  asserts  emphatically 
that  no  reliance  can  be  placed  upon  the  comparison  between 
jaws  of  different  individuals.  The  only  way  to  get  at  the  truth 
of  the  matter  is  to  examine  the  same  jaw  at  different  ages,  and 
then  compare  the  various  results.  "  This,"  says  Bell,  "I  have 
repeatedly  tried,  and  do  not  hesitate  to  say  that  the  ten  front 
permanent  teeth  occupy  a  somewhat  wider  arch  than  the  milk 
teeth   which   preceded  them."     C.   A.   Harris  ||    coincides  with 

*  Natural  History  of  Teeth.  f  Natural  History  of  Human  Teeth. 

J  Seconde  Dentition,  1819. 

§  Anatomy,  Physiology,  and  Diseases  of  the  Teeth,  1835,  2d  ed. 

II  Op.  cit. 


92  ANATOMY    AND    PHYSIOLOGY. 

Bell's  opinion,  and  states  that  the  transverse  and  perpendicular 
dimensions  of  the  anterior  portions  of  the  bone  continue  to  aug- 
ment until  the  completion  of  the  second  dentition,  and  even 
during  youth.  J.  Tomes  inclines  to  Hunter's  opinion,  and  op- 
poses the  idea  of  an  interstitial  growth  of  the  bone. 

According  to  Hiiter,*  the  growth  of  the  inferior  maxillary 
arch  in  its  perpendicular  dimensions  is  chiefly  periosteal,  while 
horizontally  it  is  the  result  of  the  expansive  osseous  groAvth. 
In  his  opinion  no  notable  growth  takes  place  after  birth  in  the 
whole  of  that  part  of  the  lower  jaw  between  the  third  grinders 
(first  permanent  molars).  Welcker's  measurements,  also,  con- 
firm this  statement.  HiAter  opposed  the  idea  of  an  interstitial 
growth  of  bone,  -while  Rich.  \  olkmann,  long  since  and  again 
recently, t  advocated  its  occurrence.  C.  Ruge|  and  Julius 
Wolff,§  also,  are  in  favor  of  the  same  view.  I,  myself,  agree 
with  the  latter,  for  the  reasons  already  given. 

There  can  be  no  doubt  that,  as  already  stated,  an  enlargement 
of  the  maxillary  arch  is  produced  chiefly  by  the  deposition  of 
osseous  substance  upon  the  facial  surface,  and  also  by  resorption 
■which  takes  place  upon  the  lingual  surface.  In  this  way  the 
front  teeth  are  pushed  forward,  and  the  back  teeth  outwards. 
This  change  of  the  location  of  the  teeth,  however,  is  conceivable 
only  in  case  resorption  also  takes  place  in  the  interior  of  the 
bone,  since,  otherwise,  the  teeth,  covered  as  they  are  by  new 
layers  upon  the  facial  surface,  must  finally  be  pressed  nearer 
the  lingual  surface,  which  evidently  is  not  the  case.  An  inter- 
stitial ri'.so7'ption  must,  therefore,  take  place.  Fox  advocates, 
to  be  sure,  a  change  of  form  in  the  maxillary  arch  during  its 
growth,  but  this  is  true  only  of  the  upper  jaw.  If  we  compare, 
he  says,  the  jaw  of  a  child  with  that  of  an  adult,  a  marked  dif- 
ference Avill  be  observed  ;  that  of  the  child  has  nearly  the  form 
of  a  semicircle,  while  that  of  the  adult  presents  a  semi-ellipse. 
These  changes  in  the  maxillary  arches  will  be  considered  at 
greater  length  farther  on.|| 

In  order  to  ascertain  tlie  relative  growth  in  the  under  jaw,  we 

*  Virchow's  Arcliiv,  9  Bd.  f  Centralblatt  fur  med.,  Wiss.,  1870. 

+  Virchow's  Archiv,  Bd.  49.  §  Ccntnilblatt  fiir  med.,  Wiss.,  18G9. 

II    Vide  p.  95,  et  seq. 


GROWTH    OF    THE    JAWS.  93 

must  first  endeavor,  if  possible,  to  select  points  that  are  not 
liable  to  change,  from  which  to  make  our  measurements.  It  is 
self-evident  that  absolute  accuracy  is  impossible,  and  that  ap- 
proximate results  only  can  be  obtained.  The  unavoidable  errors 
of  observation  acquire  greater  importance  the  smaller  the  dis- 
tances which  are  to  be  measured.  The  longitudinal  dimensions 
are  much  less  diflficult  to  ascertain  than  the  transverse  and 
perpendicular. 

I  instituted  a  series  of  measurements  of  forty-five  children's 
skulls,  with  reference  to  the  growth  in  length  of  the  inferior 
maxillary  arch,  partly  also  with  the  view  of  ascertaining  the  in- 
dividual differences,  making  use  of  a  thin  slip  of  paper  slightly 
moistened  and  accurately  adapted  to  the  peripheral  surfaces. 
Measurements  taken  by  means  of  a  pair  of  compasses  give  a 
sector,  wlien  applied  to  a  curved  object,  which  may  be  the  same 
with  different  curves.  The  mental  foramen  is  taken  as  a  fixed 
point  for  measurements  upon  the  anterior  segment  of  the  lower 
jaw  ;  it  must,  however,  be  remembered  that  the  locality  of  this 
aperture  is  not  constant.  In  the  under  jaws  of  adults  its  ante- 
rior margin  falls  sometimes  in  a  line  between  the  two  bicuspids, 
at  times  directly  under  the  first,  or  under  the  second  bicuspid, 
and  at  others  on  a  line  with  the  posterior  coronal  surface  of  the 
second  bicuspid.  -These  variations,  even  in  a  small  series  of 
under  jaws,  give  an  error  of  from  three  to  four  millimetres. 
Disregarding  the  latter,  and  employing  the  measurements  of 
the  peripheral  distance  from  the  line  of  junction  of  the  two 
halves  of  the  under  jaw  (Avhich  may  easily  be  marked  with  a 
pencil)  to  the  anterior  margin  of  the  mental  foramen,  we  found 
that,  in  a  five  months'  foetus,  the  distance  measured  10  mm.;  in 
new-born  children,  12  to  13  mm.;  in  children  from  4  to  11 
months  old,  15  to  18  mm.;  in  others  from  1  to  7  years  old,  it 
remained  about  the  same,  18  to  19  mm. ;  in  four  cases,  one  a 
child  1  year  5  months  27  days  old,  who  had  cut  the  central 
incisors,  it  reached  a  length  of  20  mm. ;  in  one  1  year  10  months 
10  days  old,  with  a  first  molar  cut,  21  mm. ;  in  a  child  5  j^ears 
old,  with  its  complete  set  of  milk  teeth,  21  mm. ;  in  one  6  years 
1  month  old,  with  a  large  set  of  teeth,  23  mm. ;  from  7  to  12 
years,  inclusive,  it  varies  from  22  to  24  mm.,  and  in  comparative 


94  ANATOMY     AND    PHYSIOLOGY. 

mcnsurements  of  adults'  under  jaws,  between  23  and  29  mm. 
If  we  disregard  extreme  cases,  we  find  the  most  notable  growth 
of  this  part  of  the  under  jaw  during  the  first  months  of  life,  and 
an  interval  of  rest  after  the  eruption  of  the  milk  teeth,  and  again 
an  increase  during  the  shedding  of  the  teeth,  amounting  to  at 
least  3  mm.  In  order  to  meet  the  objection,  that  no  account 
was  taken  of  the  thickness  of  the  facial  wall,  separate  measure- 
ments Avere  made  after  the  removal  of  the  facial  wall ;  they 
showed,  however,  as  indeed  was  anticipated,  no  material  diiference. 
Further  measurements  were  made,  in  the  same  manner  by 
means  of  a  slip  of  paper,  of  the  Avhole  length  of  the  facial  sur- 
face of  the  under  jaw  from  the  junction  of  the  halves,  which  Avas 
marked,  to  the  most  prominent  point  of  the  condyle,  which  may 
be  done  as  long  as  the  latter  does  not  project  very  far  above 
the  level  of  the  alveolar  margin.  This  peripheral  boundary 
measures,  in  a  foetus  of  five  months,  40  mm. ;  in  one  of  7  months, 
43  mm.;  in  a  new-born  child,  45  to  52  mm.;  it  increases  until 
the  fourth  month  to  58  mm.;  till  the  seventh  month  to  62  mm. ; 
till  the  first  year  to  67  mm. ;  till  the  end  of  the  second  year, 
after  the  eruption  of  the  first  molar,  to  77  mm, ;  in  the  fourth, 
fifth,  and  sixth  years,  with  the  entire  set  of  milk  teeth,  from  78 
to  S5  mm. ;  in  a  child  seven  years  old,  with  the  first  permanent 
molar,  to  100  mm.  After  this  age  such  measurements  cannot 
be  made  with  precision.  If  Ave  subtract  from  the  latter  the 
measurements  of  the  anterior  segments  of  the  tAvo  halves  of  the 
lower  jaAv,  made  from  the  median  line  as  far  as  the  anterior 
margin  of  the  mental  foramen,  Ave  obtain  a  series  of  measure- 
ments for  the  posterior  segments,  from  the  last-named  margin  to 
the  prominent  point  of  the  condyle.  This  latter  series  gives  an 
increase  of  from  30  to  77  mm.,  while  Ave  found  that  the  anterior 
segments  increased  from  10  to  23  only.  The  total  increase  rep- 
resented by  the  quotients  of  the  latter,  2.56  and  2.3  respec- 
tively, presents  a  difference  Avhich  is  due  to  the  greater  degree 
of  groAvth  of  the  posterior  segment  of  the  jaw.  J.  Tomes  em- 
ployed also  the  tubercles  on  the  lingual  surface  of  the  lower 
jaw,  which  serve  for  the  attachment  of  the  genio-hyo-glossus 
and  genio-hyoideus  muscles,  as  a  point  from  which  to  take  meas- 
urements.    According  to  my  experience,  however,  these  tuber- 


GROWTH    OF    THE    JAWS.  95 

cles  are,  often,  so  indistinct  in  the  foetus,  and  likeAvise  in  the 
new-born  child,  and  vary  so  much  in  form,  size,  and  height  in 
chihlren,  and  particularly  in  adults,  that  the  value  of  such 
measurements  appears  doubtful,  and  all  the  more  so  in  the  case 
in  hand,  from  the  fact  that  the  calculation  involves  such  small 
quantities. 

Measurements  of  sets  of  teeth,  taken  on  the  facial  margin  of 
the  alveolar  border,  from  the  line  of  junction  of  the  jaws  across 
the  necks  of  the  teeth  to  the  posterior  portion  of  the  neck  of 
the  second  bicuspid,  gave  for  half  the  set  of  lower  milk  teeth, 
32  to  34  mm.;  the  peripheral  extent  of  the  permanent  teeth, 
measured  in  the  same  manner,  varied  from  32  to  37  mm.  In 
many  cases,  therefore,  the  size  of  the  under  set  of  milk  teeth 
conforms  exactly  to  the  corresponding  segment  of  the  perma- 
nent set ;  in  some  cases  the  former  may  even  be  larger,  but 
generally  the  reverse  is  the  case. 

Just  as  the  new  layers  of  bone  are  deposited  upon  the  facial 
Avail  of  the  growing  maxillary  arch,  and  resorption  takes  place 
upon  its  lingual  surface,  so  in  the  development  of  the  posterior 
segment  of  the  jaw,  deposition  of  new  osseous  layers  takes  place 
upon  the  posterior  surface  of  the  articular  and  osseous  process, 
while  anteriorly  upon  the  coronoid  process  and  condyle  resorp- 
tion of  the  osseous  substance  ensues.  G.  M.  Humphrey*  has 
proved  this  fact  experimentally.  He  introduced  wire  ligatures 
through  the  middle  of  the  ascending  ramus  of  the  lower  jaw  of 
a  young  pig,  near  the  anterior  and  posterior  margins  of  the 
ramus,  and  ascertained  that,  after  the  expiration  of  a  certain 
interval,  the  front  loop  was  loose  and  projecting,  while  the  back 
one  lay  deeply  imbedded  within  the  posterior  portion  of  the 
ramus.  He  states  that  a  somewhat  analogous  process  occurs 
in  the  upper  jaw,  and,  on  the  whole,  agrees  with  the  views  of 
J.  Tomes. 

In  order  to  illustrate  the  changes  which  take  place  in  the  arch 
of  the  milk  teeth,  in  comparison  with  that  of  the  permanent 
teeth,  the  arches  formed  by  a  permanent  and  milk  set  and  that 
of  the  outer  alveolar  plate  of  a  seven  months'  foetus,  placed  one 

*  Triinsactions  of  the  Cambridge  Philosophical  Society,  vol.  xi,  part  1. 


96 


ANATOMY    AND    PHYSIOLOGY. 


inside  the  other,  were  emploj'ed  as  a  basis  for  measurements. 
The  commencing  and  terminal  points  of  the  measurements  were 
as  follows :  The  centre  of  the  space  between  the  edges  of  the 
two  central  incisors,  and  the  points  of  the  intersection  of  the 
posterior  coronal  with  the  masticating  surfaces  of  the  crowns  of 
the  second  permanent  bicuspids  and  milk  molars,  and,  in  the 
seven  months'  foetus,  the  point  of  junction  of  the  two  halves  of 
the  jaw,  upon  the  facial  alveolar  margin,  and  the  outer  extremity 
of  the  alveolus  for  the  second  milk  molar.  As  they  were  made 
upon  a  well-developed  set  of  milk  teeth  and  a  large  set  of  a 
man  twenty-two  years  old,  they  are  not  the  mean  measurements 
and  have  no  claim  to  a  very  general  application. 


Fig.  27 


In  the  upper  jaw  (Fig.  27),  it  will  be  seen  that  the  curve 
a,  a',  obtained  by  the  above  measurements  in  a  seven  months' 
foetus,  is  very  nearly  the  segment  of  a  circle ;  in  the  milk  set, 
6,  6',  it  describes  a  concentric  arc  of  a  circle ;  in  the  permanent 
set,  on  the  other  hand,  it  has  changed  into  the  segment  of  an 


*  Fig.  27. — Diagram  illustrating  the  changes  in  the  dental  arch  during 
the  growth  of  the  upper  jaw.  (a),  lowest  point  in  the  junction  of  the  anterior 
portions  of  the  two  segments  of  the  upper  jaw,  from  a  foetus  in  the  seventh 
month  ;  (6),  central  point  of  the  space  between  the  edges  of  the  two  central 
incisors  of  a  set  of  milk  teeth;  (c),  the  same  of  a  permanent  set;  («'),  pos- 
terior and  external  termination  of  the  alveolus  for  the  second  milk  molar; 
(//),  point  of  intersection  of  the  posterior  coronal  with  the  masticating  sur- 
face of  the  second  milk  molar;  (c/),  point  of  intersection  of  the  posterior 
coronal  with  the  masticating  surface  of  the  second  permanent  bicuspid. 
Natural  size. 


GROWTH    OF    THE    JAWS. 


97 


ellipse,  f,  c' .  We  find,  further,  that  the  point  a  has  advanced 
to  b  and  finally  to  c,  anteriorly,  while  posteriorly  the  displace- 
ment of  a'  to  h'  measures  the  same  as  that  of  a  to  h,  but  that 
the  point  c'  is  displaced  comparatively  farther  outwards;  in 
other  words,  a,  b  =  a',  b\  but  b,  c  <.  b,'  e' .  The  permanent 
second  bicuspid  occupies  a  more  outward  position  towards  the 
face  than  the  permanent  central  incisor. 

A  similar  method  was  applied  to  the  lower  jaw  (Fig.  28),  and 
it  was  found  that,  in  corresponding  segments,  the  increase  in 
growth  is  less  than  in  the  upper  jaw,  and  that  the  curves  con- 


FlG.  28.* 


tinue  nearly  parallel,  that  is  tosay  «5  =  a'<^',  and  5  c=5'c' nearly  ; 
the  second  permanent  bicuspid  is  placed  only  a  little  farther  ex- 
ternally than  the  second  milk  molar,  and  does  not,  as  is  the 
case  in  the  upper  jaw,  undergo  a  notably  greater  facial  displace- 
ment than  the  central  permanent  incisor.  If  a  moderately 
well-developed  set  of  permanent  teeth  be  chosen  and  compared 
with  a  large,  well-developed  set  of  milk  teeth,  the  curves  b,  b' 
and  c,  c'  coincide,  and  the  latter  curve  may  be  met  with  even 
smaller  than  the  first. 


■^  Fig.  '28. — Diagram  illustrating  the  change  in  the  dental  arch,  during  the 
growth  of  the  lower  jaw  ;  a,  the  highest  point  in  the  line  of  junction  of  the 
anterior  surfaces  of  the  two  segments  of  the  lower  jaw  in  a  foetus  of  seven 
months.  The  rest  of  the  letters  indicate  corresponding  points  with  those  in 
the  last  figure.     Natural  size, 

7 


PART  II. 

PATHOLOGY. 

I.  IRREGULARITIES  IN  THE  FORMATION  OF  TEETH. 

The  teeth  are  subject  to  manifold  anomalies  which  are  de- 
serving of  careful  consideration,  since,  in  addition  to  the  mere 
theoretical  interest  which  they  possess,  many  require  a  special 
operative  treatment.  They  present  for  particular  consideration 
abnormal  conditions  in  respect  of  size,  number,  arrangement, 
position,  and  structure.  The  permanent  teeth  will  be  considered 
first,  since  their  irregularities  are  the  more  important  and  of 
more  frequent  occurrence. 

1.  Irregularities  of  Size. 

Excessive  size,  so  great  as  to  constitute  a  disfigurement,  is 
seldom  presented  by  the  entire  rows  of  permanent  teeth,  more 
frequently  by  the  front  ones  alone.  With  this  condition,  the 
crowns  of  the  upper  central  incisors  are  particularly  conspicuous, 
in  consequence  of  their  very  great  extent  of  surface,  while 
their  roots  remain  comparatively  short  and  stunted.  Sometimes 
the  excessive  size  of  the  upper  central  incisors  is  compensated 
for  by  the  lesser,  retarded  growth  of  the  laterals.  Occasionally 
the  excessive  growth  involves  both  the  crowns  and  the  roots  of 
the  canine  teeth,  which  then  resemble  the  fangs  of  animals. 
Disproportions  in  size  between  the  jaw  and  teeth  are  accom- 
panied by  corresponding  changes  in  the  arrangement  of  the 
latter  which  will  be  considered  at  length  in  subsequent  pages. 

Excessive  growth  is  limited  to  one  or  another  tooth,  and 
must  not  be  confounded  with  the  excessive  size  occasioned  by 
the  coalescence  of  two  teeth,  the  incisors,  for  example,  a  mis- 
take very  easily  made,  since  the  longitudinal  groove  which  is 


IRREGULARITIES    OF    NUMBER.  99 

produced  by  the  coalescence  of  the  teeth  is  perceptible  on  the 
roots  only,  and  not  upon  the  blended  crowns. 

On  the  other  hand,  teeth  may  not  attain  the  average  size, 
and  still  there  may  be  no  interruption  in  the  contiguity  of  the 
dental  range.  If,  however,  the  maxillary  arch  is  too  wide,  in 
proportion  to  the  dental  arch,  intervals  occur  now  and  then  be- 
tween the  teeth,  especially  between  the  front  ones.  These  in- 
tervals will  be  so  much  the  more  conspicuous,  if  cither  of  the 
front  teeth  is  unusually  small  in  comparison  with  the  others. 
They  occur  most  frequently  between  the  two  upper  central,  and 
lateral  incisors,  and  more  rarely  betAveen  the  lower  centrals. 
The  interval  between  the  two  upper  centrals  is  often  so  wide, 
and  occasions  such  a  disfigurement  that  Heider  was  required 
frequently  to  fill  up  the  abnormal  space  by  the  insertion  of  a 
tooth.  In  many  cases,  these  large  intervals  are  occasioned  by 
the  prolonged  retention  of  a  large  milk  incisor,  which  prevents 
the  normal  advance  and  approximation  of  the  two  permanent 
incisors.  Generally,  however,  they  are  due  to  the  great  resist- 
ance of  the  alveolar  septum,  or  the  suture  which  unites  the  two 
segments  of  the  upper  jaw.  Wisdom  teeth,  particularly,  are 
liable  to  be  stunted  in  their  growth. 

In  many  children,  milk  teeth  are  found  so  uncommonly  large 
and  strong,  that  they  may  easily  be  mistaken  for  permanent 
teeth,  and  on  the  contrary,  in  others,  they  are  remarkably 
small,  and  at  times,  the  milk  incisors,  for  example,  do  not 
afford  surface  enough  for  the  application  of  an  ordinary  pair  of 
children's  forceps,  without  danger  of  grasping  the  contiguous 
tooth  at  the  same  time.  When  the  milk  teeth  are  too  large,  the 
incisors,  in  particular,  frequently  overlap  one  another  on  account 
of  the  deficiency  of  space.  Milk  canine  teeth,  both  in  the 
upper  and  lower  jaw,  sometimes  are  unusually  long  and  pointed. 

2.  Irregularities  of  Number. 

Deviations  from  the  normal  number  occur  more  frequently 
■with  the  permanent  than  with  the  milk  teeth,  and  a  number  of 
teeth  less  than  normal  is  observed  more  often,  perhaps,  than 
the  opposite  condition.  J.  Tomes,  on  the  contrary,  asserts  that 
an  excess  of  the  normal  number  is  perhaps  more  common. 


100  PATUOLOGY. 

Tlic  excess  of  tlie  normal  number  of  teeth  is  either  alsolute^ 
that  is  to  say,  there  are  more  than  the  thirty-two  normal  teeth 
present ;  or  it  is  relative  if  there  is  an  excess  of  one  or  another 
kind,  while  the  total  number  does  not  exceed,  and,  indeed, 
may  even  be  less  than  the  normal  number.  If  it  is  desired 
to  enumerate  accurately  the  number  of  teeth  in  a  set,  it  is 
not  sufficient  to  give  merely  the  total  number  of  teeth  existing, 
but  the  different  kinds  of  teeth  should  be  enumerated  sepa- 
rately, and  then  all  the  teeth  together.  An  adult  may  have 
the  requisite  number  of  thirty-two  teeth,  and  still  present  both 
a  deficiency  and  an  excess  of  one  or  more  teeth.  It  may  happen 
that  the  upper  jaw  contains  two  supernumerary  lateral  incisors, 
while  the  wisdom  teeth  are  Avanting.  Hence  the  total  number 
is  not  altered  but  remains  thirty-two,  and  yet  there  is  an  excess 
and  a  deficiency  of  two  teeth  to  be  specified. 

Siqjernumerajnj  teeth  may  be  divided  into  two  groups,  those 
which  can  be  ranked  with  one  or  another  of  the  .members  of  the 
dental  series,  and  those  which  differ  in  form  from  the  latter, 
called  the  conical  teeth  (Dutten-oder  Zapfenziihne). 

Those  belonging  to  the  first  group  are,  most  frequently,  inci- 
sors and  bicuspids.  Sometimes  five,  and  in  very  rare  cases,  six 
incisors  instead  of  four  are  met  with  in  one  jaw.  The  super- 
numerary tooth  usually  is  a  lateral  incisor,  and  generally  is  so 
well  arranged  in  the  series  that  this  anomaly  easily  escapes  ob- 
servation, especially  in  the  under  jaw. 

An  extra  canine  tooth  has  been  observed,  but  it  is  a  very  un- 
common occurrence.  Tlie  cases  in  which  a  milk  tooth  is  re- 
tained in  later  life  in  close  proximity  to  a  permanent  one, 
evidently  do  not  belong  to  this  class,  but  are  liable  to  be  misin- 
terpreted by  an  inexperienced  observer.  Ileider  observed  a 
remarkable  case,  that  of  a  woman  who  had  several  canine 
teeth  in  succession,  which,  to  be  sure,  Avere  stunted  in  their 
growth.  Three  months  after  he  extracted  the  well- developed 
canine,  which  had  become  diseased,  a  hard  body,  resembling 
the  latter,  made  its  appearance  in  the  upper  part  of  the  socket, 
upon  the  external  surface  of  the  gum.  It  was  of  the  size  of  a 
rice-kernel,  and  its  extremity  Avas  covered  with  enamel.  About 
the  same  interval  having  elapsed  after  the  extraction  of   the 


IRREGULARITIES    OF    NUMBER, 


101 


latter,  a  second,  and  finally  a  third  appeared,  so  that  in  the 
course  of  a  year  three  such  canines,  each  provided  Avith  its  root, 
were  extracted  from  this  woman's  jaw.  When  three,  instead 
of  two,  bicuspids  are  met  with,  the  supernumerary  one  gener- 
ally stands  inside  tlie  dental  range,  towards  the  tongue,  crowded 
into  the  space  between  the  two  normal  bicuspids,  so  that  to- 
gether they  form  an  equilateral  triangle.  In  rare  cases,  three 
bicuspids  are  met  with  on  each  side,  but  scarcely  ever  three  in 
the  upper  and  under  jaw  at  the  same  time. 

Wisdom  teeth  are  sometimes  duplicated,  one  standing  within, 
and  the  other  without  the  dental 
range.  The  latter  is  always  the 
supernumernry  tooth,  occurs 
upon  the  outer  side  of  the  one 
in  the  range,  and  generally  has 
a  much  smaller  crown  and  a 
stunted,  roundish  root.  Super- 
numerary molars  are  extremely 
rare,  and  still  more  rare  is  their 
arrangement  in  the  normal  den- 
tal row,  as  in  the  case  of  a  set, 
belonging  to  a  negro,  which,  be- 
sides four  molars  in  each  maxil- 
lary segment,  contained  a  supernumerary  bicuspid,  making 
altogether  five  teeth  more  than  in  the  normal  condition  (Figs. 
29  and  30).  This  case  suggests  further  inquiry,  whether  super- 
numerary molars  occur  more  frequently,  and  anomalies  of  posi- 
tion more  rarely,  and  also  whether  the  anterior  segment  formed 
by  the  inferior  dental  arch  is  more  circular,  and  the  jaws  longer, 
in  the  negro  than  in  the  Caucasian  race?t 


*  Fig.  29. — Shows  supernumerary  molars  in  the  upper  jaw,  from  the  skull 
of  H  negro  (for  the  use  of  which  the  author  is  indebted  to  Prof.  Langer). 
The  set  of  teeth  is  remarkably  well  developed  and  regular.  Behind  the  three 
large,  well-developed  molars,  upon  the  right  side,  the  wisdom  tooth  is  placed 
in  the  dental  range  ;  on  the  left  side  it  has  not  yet  protruded,  but  is  imbedded 
in  the  tuberosity,  and  may  bo  seen  in  the  opening  made  in  the  part.  Two- 
thirds  natural  size. 

f  J.  Mummery  (Transactions  of  the  Odontological  Society  of  Great 
Britain,  New   Series,   vol.   ii)    ascertained   that  with   the   Ashantees,  the 


102 


PATHOLOGY. 


An  excess  of  normally-shaped  milh  teeth  is  occasioned,  usually, 
by  one  or  another  supernumerary  incisor. 


Fig.  30.* 


The  second  group  of  supernumerary  teeth  includes  the  so- 
called  conical  teeth,  which  can  be  ranked  Avitli  neither  of  the 
four  kinds  of  teeth.  They  resemble  most  the  canine  teeth  in 
form,  though  there  is  no  danger  of  confounding  the  two.  In 
most  cases  the  crown,  as  well  as  the  invariably  single  root,  is 
conical,  and  the  three  dental  tissues  are  well  developed ;  the 


inhabitants  of  Dahomy  and  a  few  neighboring  tribes  on  the  west  coast  of 
Africa,  the  dental  arches  are  very  wide,  and  adduced  the  frequent  occurrence 
of  supernumerary  teeth  among  them  as  a  noteworthy  fact.  He  observed 
six  cases,  in  each  of  which  there  was  a  fourth  eztra  molar  in  the  upper  jaw, 
in  five  of  the  cases  on  both  sides,  and  in  the  other  on  one  side;  three  cases 
of  an  extra  third  upper  bicuspid  on  one  side;  an  extra  upper  canine  tooth 
in  a  regular  position  on  each  side,  and  an  extra  well-developed  right  upper 
central  incisor.  In  the  under  jaw  he  did  not  meet  with  a  single  example  of 
a  supernumerary  tooth,  but  the  third  molars  were  frequently  larger  than  the 
second. 

*  Fio.  30  shows  three  supernumerary  teeth  in  the  lower  jaw,  from  the 
same  negro's  skull.  The  arrangement  of  the  dental  row  is  regular.  On  the 
left  side,  and  lingual  surface,  between  the  two  bicuspids,  lies  a  supernumerary 
bicuspid,  which  is  twisted  so  that  its  lingual  coronal  surface  is  turned  towards 
the  median  line  of  the  jaw.  The  wisdom  teeth  on  both  sides  are  located 
behind  the  three  large  molars.     Two-thirds  natural  size. 


IRREGULARITIES    OF    NUMBER. 


103 


Fig.  31. t 


exposed  upper  surface  is  encircled,  sometimes,  by  transverse 
grooves;  the  pulp-cavity  is  elongated  into  a  single  dental  canal. 
In  rare  cases  the  crown  is  three-sided,  resembling  a  pyramid,  in 
■which  cases  the  root,  also,  presents  similar  surfaces,  but  the  planes 
of  the  coronal  surfaces  correspond  to  the  edges  of  the  roots 
(Atlas,  Fig.  1).*  Sometimes  these  teeth  are  disproportionately 
short  and  thick,  but  ordinarily  they  are  slender,  and  present 
many  variations  in  respect  of  size. 

Their  locality  is  variable  ;  they  are  placed  either  among  the 
permanent  teeth  in  the  dental 
range,  or,  as  is  generally  the 
case,  stand  upon  one  side  of 
the  latter.  They  are  found 
implanted  between  the  central 
upper  incisors  (Fig.  31),  or 
between  the  upper  centrals 
and  laterals,  frequently  be- 
hind the  centrals  or  laterals, 
or  in  pairs  on  the  palatal  por- 
tion of  the  upper  jaw,  and 
also  at  the  side  of  the  bicus- 
pids or  molars  in  both  the 
upper  and  lower  jaws.  They 
seem  never  to  occur  in  the  vicinity  of  the  lower  incisors. 

Their  eruption  takes  place  during  the  first  or  second  dentition, 
or  in  the  interval  between  the  two.  J.  Tomes  reports  two  cases, 
which  occurred  in  his  practice,  of  supernumerary  conical  teeth 


*  Fox,  Nat.  Hist,  of  tins  Human  Teeth,  p.  69,  with  instructive  illustrations. 

t  Fig.  31  shows  a  supernumerary  tooth  situated  at  the  right  side  of  the 
median  line  and  between  the  central  incisors  of  the  upper  jaw.  It  has  a 
conical  crown,  is  well  covered  with  enamel,  and  somewhat  worn  away  trans- 
versely at  the  extremity.  The  incisors  upon  the  right  side  slightly  overlap, 
while  those  upon  the  left  side  stand  within  the  dental  range.  The  right 
segment  of  the  dental  arch  extends  about  three  millimetres  more  posteriorly 
than  the  left,  on  account  of  the  insertion  of  the  supernumerary  tooth.  The 
latter  probably  emerged  sooner  than  the  right  incisors,  and  produced  only 
a  slight  variation  in  the  dental  arrangement,  on  account  of  the  breadth  of 
the  maxillary  arch.  Two-thirds  natural  size.  (The  author  is  indebted  to 
Prof.  Langer  for  the  use  of  this  specimen.) 


104  PATHOLOGY. 

in  children  five  years  of  age.  In  most  cases,  however,  they 
belong  to  the  second  dentition,  and  are  permanent.  The  ques- 
tion as  to  whether  they  are  secondary  developments  from  the 
germs  of  milk  or  permanent  teeth  may  be  answered  negatively, 
inasmuch  as  they  differ  in  shape  from  normal  teeth.  Reasoning 
from  the  latter  point  of  view,  it  is  more  probable  that  they  are 
independent  dental  germs,  products  of  the  superficial  mucous 
membrane,  and  do  not  originate,  like  the  permanent  teeth,  from 
secondary  germs. 

As  their  eruption  is  coincident,  generally,  with  that  of  the  per- 
manent teeth,  they  are  more  likely  to  interfere  with  the  regular 
arrangement  of  the  latter  when  the  maxillary  arch  is  too  narrow 
or  too  short,  and  are  the  origin  of  a  variety  of  anomalies  in  the 
position  of  teeth.  As  they  occasion  a  disfigurement,  and  inter- 
fere with  articulation  when  they  are  situated  in  the  palate,  in 
which  case  also  the  tongue  is  especially  liable  to  injury,  further, 
as  they  favor  the  occurrence  of  caries  when  they  are  placed  by 
the  side  of  bicuspids  or  molars,  and,  finally,  as  they  are  of  no 
particular  service,  if  allowed  to  remain,  it  is  customary  to  ex- 
tract them.  A  thorough  acquaintance  with  them,  therefore,  is 
indispensable  to  the  practitioner.  In  cases  where  the  super- 
numerary teeth  are  well  arranged  in  the  dental  row  between  the 
central  incisors,  or  occupy  the  position  of  lateral  incisors,  it  is  the 
common  practice  to  allow  them  to  remain,  since  in  the  former 
case  a  disfiguring  oblique  position  of  the  permanent  teeth  is  to 
be  anticipated  under  any  circumstances,  and  in  the  latter  it  can- 
not be  expected  that  the  sockets  of  the  supernumerary  teeth 
will  be  filled  up  by  a  lateral  displacement  of  the  remaining  teeth. 
The  treatment  is  to  be  determined  only  by  a  careful  considera- 
tion of  the  circumstances  in  each  case. 

The  extraction  of  such  teeth  from  their  alveoli  is  attended 
with  no  difiiculty,  on  account  of  the  favorable  form  of  their  roots, 
but  the  adaptation  of  the  forceps  is  sometimes  interfered  with  in 
certain  localities. 

Deficiency  of  Teeth. — Cases  of  the  absence  of  all  the  perma- 
nent teeth  certainly  are  very  rare.     Linderer*  reported  the  case 

*  Zahnlieilkuiule,  p.  137. 


IRREGULARITIES    OF    NUMBER.  105 

of  a  woman  fifty  years  of  age,  who  never  had  any  teeth.  The 
examination  of  her  mouth  gave  no  grounds  for  doubting  the 
truth  of  her  assertion.  J.  Tomes*  relates  one  or  two  simihir 
cases,  though  in  his  practice  he  has  never  met  with  a  person 
who  did  not  present  some  indication  of  second  teeth.  Carabelli,t 
also,  never  observed  such  a  case ;  and  he  asserts  that  the  entire 
absence  is  an  improbable,  though  not  an  impossible  occurrence. 
Heider,  in  the  course  of  twenty-three  j^ears,  never  met  with  an 
instance  of  total  deficiency. 

Sometimes,  though  rarely,  very  inanij  of  the  permanent  teeth 
are  wanting,  the  wdiole  set  containing  but  a  few  teeth.  Such 
cases  now  and  then  come  under  the  observation  of  extensive 
practitioners  and  are  referred  to  in  nearly  all  the  larger  works 
on  dentistry.  Fox  saw  a  young  woman  about  twenty  years  of 
age,  who  retained  the  central  milk  incisors  of  the  under  jaw 
and,  in  the  upper  jaw,  all  the  milk  incisors  except  one  lateral, 
which  had  fallen  out.  He  also  relates  a  case  in  which  there 
were  only  four  teeth  in  each  jaw,  and  still  another,  in  which 
there  was  but  one  incisor  in  the  upper  jaw.  J.  Tomes  relates 
an  instance  where  there  was  one  molar  on  each  side  of  the  upper 
and  lower  jaw.  These  four  molars,  together  with  four  incisors, 
two  in  each  jaw,  composed  all  the  permanent  teeth.  It  is  a 
curious  fact  that  the  milk  teeth  presented  no  peculiarities  in 
regard  to  their  number,  or  the  time  at  which  they  were  shed, 
according  to  the  statements  of  the  patient  and  his  friends. 

The  absence  of  single  permatient  teeth  is  not  of  rare  occur- 
rence. The  utmost  caution  is  requisite  in  judging  in  a  given 
case,  whether  a  tooth  is  wanting  naturally  or  has  been  detached, 
since  the  statements  of  patients  are  exceedingly  untrustworthy; 
sometimes  they  cannot  remember  wdiich  teeth,  if  any,  have  been 
extracted.  A  thorough  examination  of  the  teeth,  which  remain, 
of  the  sockets  and  jaws,  is  necessary  before  coming  to  a  decision. 
Especial  attention  should  also  be  given  to  the  fact  whether  such 
defects  are  hereditary  or  not,  for  it  often  happens  that  the  same 
tooth  is  deficient  M'ith  several  members  of  the  same  family. 

Individuals  are  met  with,  now  and  then,  wdio  have  only  one 

*  Op.  cit.,  p.  206.  t  Anatomie  des  Mundes,  p.  127. 


106  PATHOLOaY. 

large  incisor  in  the  upper  jaw,  Avliich  mars  considerably  the  sym- 
metry of  the  dental  range.  When  this  is  seen,  it  may  be  as- 
sumed, almost  with  certainty,  that  the  second  incisor,  now 
missing,  formerly  stood  in  its  place,  and  was  lost  by  a  blow, 
fall,  &c.,  soon  after  it  was  cut.  Heider  mentions  a  case  which 
occurred  in  his  practice,  where  a  surgeon,  after  extracting  an 
upper  cential  milk  incisor,  the  root  of  which  was  entirely  ab- 
sorbed, mistook  the  projecting  extremity  of  the  permanent  in- 
cisor for  the  broken  root,  seized  it,  and  consequently  extracted 
the  entire  immature,  secondary  tooth.  Afterwards  the  parents 
brought  the  latter  secondary  tooth  to  him,  to  be  replaced  in  the 
child's  jaw,  but  this,  of  course,  was  impracticable,  with  the  root 
only  half  developed. 

Many  similar  mistakes  are  liable  to  be  made  with  the  rest 
of  the  milk  teeth,  and  the  fact  that  these  pass  unnoticed  in  so 
many  cases,  accounts  for  the  frequent  deficiency  in  the  number 
of  the  secondary  teeth,  particularly  when  it  is  considered  that 
the  gaps  which  remain  after  the  extraction  of  teeth  at  such  an 
early  age  are  entirely  effaced  by  the  approximation  of  the  suc- 
ceeding teeth,  so  that  the  dental  range  presents  a  complete  ap- 
pearance, and,  in  such  cases,  many  are  entirely  ignorant  of  the 
fact  of  the  loss  of  a  tooth,  thinking  nature  failed  to  produce  a 
secondary  tooth. 

In  many  cases  the  lateral  incisors  are  wanting  upon  one  side 
only,  but  a  deficiency  upon  both  sides  is  of  more  common  occur- 
rence. Of  the  canines,  sometimes  one  is  absent  in  the  upper  or 
under  jaw,  or  both  are  wanting  and,  almost  always,  are  concealed 
within  the  jaw,  as  in  the  case,  Atlas,  Fig.  4.  Sometimes  only 
one  bicuspid  is  present  upon  one  or  both  sides,  and  generally 
that  is  the  first ;  the  second  bicuspid  is  often  absent,  but  usually 
it  is  concealed  in  the  jaw,  its  eruption  being  prevented  by  Avant 
of  space,  since  it  is  obliged  to  emerge  between  the  first  bicus- 
pid and  first  molar.  As  is  well  known,  sometimes  the  upper, 
and,  at  others,  tlie  under  wisdom  tooth  is  out  of  sight  entirely, 
perhaps  on  account  of  the  non-formation  of  the  germs,  or,  it  may 
be  that  they, lie  imbedded  in  the  jaw  and  are  prevented  from 
emerging  in  consequence  of  want  of  space,  which  latter  is  fre- 


IRREGULARITIES    OF    NUMBER.  107 

quently  the  case  with  the  lower  wisdom  teeth,  on  account  of  the 
marked  projection  of  the  coronoid  process  in  front. 

The  inspection  of  the  rehations  of  the  locality  and  thorough 
examination  of  the  neighboring  sockets  and  portions  of  the  jaw 
w^ill  indicate  whether  disproportion  of  space  hinders  the  develop- 
ment of  the  tooth,  or  whether  the  latter  is  actually  wantino-. 
By  a  careful  examination  of  the  jaw  with  the  finger,  the  bulging 
corresponding  with  the  location  of  the  concealed  tooth  may 
frequently  be  felt  distinctly,  and  often  furnishes  presumptive 
evidence  in  regard  to  the  position  of  the  latter.  Operative  in- 
terference should  very  seldom  be  decided  upon  at  once ;  an 
attempt  should  not  be  made  to  provide  room  by  the  removal  of 
permanent  or  milk  teeth  which  stand  in  the  way,  until,  after 
repeated  examinations,  there  remains  no  doubt  about  the  exist- 
ence of  a  concealed  tooth,  the  position  and  development  of  which 
may  be  assumed  to  be  normal,  with  a  considerable  degree  of 
probability,  upon  the  ground  of  the  prominent  bulging  of  the 
jaw  which  has  been  mentioned. 

The  absence  of  all  the  milk  teeth  is  allowed  to  be  an  occur- 
rence of  extreme  rarity.  J.  Tomes*  has  never  had  the  oppor- 
tunity of  examining  such  a  case,  either  in  a  living  subject  or  in 
a  prepared  specimen.  He  was  informed,  recently,  by  a  gentle- 
man, that  a  member  of  his  family,  a  female  about  fifteen  years 
of  age,  had  been  from  the  time  of  her  birth,  and  was  then,  en- 
tirely edentulous,  and  that  the  lower  part  of  her  face  preserved 
the  appearance  usually  presented  by  a  child  before  the  eruption 
of  the  teeth. 

A  diminution  in  the  ordinary  number  of  milk  teeth  is  not  so 
rare ;  generally  in  such  cases  the  lateral  incisors  are  absent. 
In  regard  to  this  anomaly,  however,  it  is  to  be  borne  in  mind 
that  the  deficiency  of  one  or  another  tooth  may  only  be  appar- 
ent, since,  in  consequence  of  the  contracted  space  their  erup- 
tion may  be  utterly  impossible,  or  else  they  can  emerge  only 
partially.  Suppuration  of  a  dental  sac  or  alveolus,  which  occurs 
in  scrofulous  children  particularly,  involves,  of  course,  the  de- 
struction of  the  corresponding  tooth,  and  deserves  mention  in 
connection  with  the  subject  of  the  deficiency  of  teeth. 

*  Op.  cit  ,  p.  39. 


108  pathology. 

3.  Irregularities  of  Arrangement. 

A.  Irregularities  in  the  Arrangement  of  the  Entire  Dental 
Archf'S. — In  the  deviations  of  the  set  from  the  normal  position, 
■which  occur  in  the  Caucasian  races,  either  the  upper  or  the 
loAver  jaw,  or  both  together,  are  more  or  less  elongated  ante- 
riorly ;  their  alveolar  processes  describe  an  unusually  broad  or 
narrow,  oval  or  circular  arch ;  the  undulatory  curves  of  the 
dental  arches  are  more  shallow  or  deeper  than  is  the  case  ordi- 
narily; the  six  anterior  sockets  of  one  or  both  jaws  are  more 
everted  or  inverted ;  the  teeth,  implanted  in  these  sockets,  have 
very  long  or  short,  broad  or  narrow  crowns,  and  the  latter  are 
■well  or  badly  arranged ;  the  dental  arch  presents  an  abnormal 
internal  or  external  curvature,  together  with  a  frequent  Avant  of 
symmetry  between  the  two  halves  of  the  jaw ;  the  molars  pre- 
sent an  excessive  mesial  or  lateral  inclination,  and  the  ascending 
ramus  of  the  lower  jaw  is  too  short  or  too  long.  These  exam- 
ples of  the  principal  irregularities  which  occur  in  the  position 
of  sets  of  teeth,  give  rise  also  to  various  deviations  from  the 
normal  conformation  of  the  mouth. 

a.  Sometimes  all  the  incisors  and  canine  teeth,  particularly 
those  in  the  under  jaw,  instead  of  being  arranged  side  by  side, 
in  the  form  of  an  arch,  are  placed  in  a  straight  line  so  that  the 
canine  teeth  meet  the  bicuspids  nearl}^  at  right  angles.  The 
lower  half  of  the  face  thus  loses  its  oval  curve,  becomes  broader, 
and  gives  rise  to  the  flat  mouth.  A  less  degree  of  this  irregu- 
larity is  produced  very  frequently  by  a  slight  overlapping  of 
the  crowns  of  the  lower  incisors. 

b.  If  the  middle  portions  of  the  two  alveolar  arches  project 
forwards  considerably,  and,  at  the  same  time,  are  everted,  then 
the  canine  teeth  and  incisors,  implanted  in  these  portions,  will 
also  project  obliquely  forwards,  and  this  gives  rise  to  the  so- 
called  negro  mouth  (os  gethiopum).  As,  with  this  irregularity, 
the  front  teeth  in  closing  come  together  obliquely,  or  not  at  all, 
the  pressure  and  counterpressure  necessary  for  their  fixation 
cannot  take  place,  and  consequently  such  teeth  emerge  gradu- 
ally from  their  cells,  appear  to  grow  longer,  and  finally  fall  out 
much  earlier  than  others. 


IRREGULARITIES    OF    ARRANGEMENT.  109 

c.  The  alveolar  process  of  the  upper  jaw  is  often  unusually 
deep  and  very  prominent;  the  teeth  implanted  in  it  being 
very  long  and  generally  broad,  the  incisors  and  canines  are 
pushed  outward  so  far,  that  between  them  and  the  under  teeth 
there  is  left  a  vacant  space,  in  some  cases  five  or  six  lines  in 
width;  frequently  the  palatal  arch  forms  a  sharp  curve  and  is 
narrow,  and  the  upper  bicuspids  and  molars  are  everted,  al- 
though to  a  less  degree  than  the  front  teeth,  so  that  merely 
their  internal  coronal  cusps  and  the  outer  coronal  edo;es  of  the 
corresponding  under  teeth  come  in  contact;  in  these  cases,  the 
labial  fissure  is  wide  and  the  upper  lip  usually  very  short ;  the 
inferior  maxillary  arch  presents  a  contracted  appearance  ;  when 
the  mouth  is  closed,  the  lower  lip  lies  behind  the  upper  front 
teeth,  and  the  lower  incisors  impinge  upon  the  posterior  gingival 
portions  of  the  upper  teeth.  As  with  such  an  arrangement  of 
the  dental  arches,  and  such  a  misshaped  mouth,  a  person  ex- 
poses nearly  all  the  upper  teeth,  together  with  the  anterior  por- 
tion of  the  upper  gum,  especially  in  speaking  and  laughing,  this 
deformity  is  usually  call  the  grinning  mouth  (Fletschenmund). 
J.  Tomes*  calls  attention  to  the  fact  that,  in  most  of  these 
cases,  the  molars  are  unusually  short,  and  finds  that  there  is  a 
short  alveolar  process,  and  a  short  rectangular  ascending  ramus 
of  the  lower  jaw.  This  conformation  he  regards  as  probably 
the  primary  cause  of  this  deformity.  G.  Prochaska,f  in  a  skull 
presenting  an  irregularity  in  the  position  of  the  teeth,  in  Avhich 
the  lower  incisors  stood  three  lines  behind  the  upper  ones,  when 
the  jaws  were  approximated,  observed  that  the  convexity  of  the 
superior  alveolar  arch,  in  comparison  with  that  of  the  under  jaw, 
was  unusually  great. 

d.  Sometimes  the  lower  incisors  and  canine  teeth  are  half  an 
inch  in  advance  of  the  corresponding  teeth  of  tlie  upper  jaw, 
and,  in  such  cases,  the  crowns  of  the  lower  front  teeth  fre- 
quently are  so  deep  as  entirely  to  conceal  the  upper  incisors, 
when  the  jaws  are  closed.  The  prominent  under  lip  oveidaps 
the   contracted   upper  one,    and  the  chin  is  thrown  forwards. 


*  Op.  cit.,  p.  124. 

f  Observ.  Anat.  de  Decremento  Dentiura,  1800. 


110  PATHOLOGY. 

This  deformity  is  produced  by  a  want  of  relationship  between 
the  superior  maxillary  arch,  which  is  shorter,  and  the  inferior, 
which  is  longer,  than  in  the  normal  condition,  and  by  an  exces- 
sive development  of  the  alveolar  portion  of  the  lower  jaw. 
According  to  Gynnel,  a  natural,  partial  luxation,  which  takes 
place  at  the  articulation  of  the  lower  jaw,  is  also  to  be  taken 
into  account,  as  contributing  to  its  production.  The  deformity 
of  the  mouth  which  it  occasions  is  called  "  underhung  "  (das 
Hundemaul)  (la  ganache  of  the  French). 

e.  AVhen  the  six  upper  front  teeth  are  placed  directly  over 
the  lower  ones,  so  that  their  respective  incisive  margins  meet 
edge  to  edge,  there  results  the  so-called  upriglit  set,  one  of  the 
most  frequent  irregularities,  and  accompanied,  usually,  by  the  flat 
mouth.  This  position  of  the  teeth  is  very  favorable  for  masti- 
cation, for,  in  biting,  the  teeth  act  in  a  perpendicular  line  and 
become  firmly  pressed  into  their  sockets,  and  the  masticating 
surfaces  operate  to  the  best  advantage,  while  the  teeth  are  not 
so  likely  to  be  loosened  as  is  the  case  when  the  front  teeth  are 
everted  ;  on  the  other  hand,  they  are  subjected  to  more  Avear 
from  attrition,  so  that  the  incisive  edges  and  points  become 
transformed  into  small  masticating  surfaces. 

/.  Another  irregularity  of  the  dental  arches  occurs  when  the 
incisive  margins  of  the  front  teeth  meet  edge  to  edge,  but  both 
the  upper  and  under  incisors  are  inverted,  producing  a  sort  of 
channel,  opening  outwards,  where  the  dental  arches  are  in  con- 
tact. In  these  cases,  the  chin  projects  very  much,  and  the  lips 
are  considerably  retracted.  The  mouth  shaped  by  this  irregu- 
larity is  called,  from  its  resemblance  to  that  of  an  old  person, 
the  Seville  mouth  (os  senile). 

g.  Cases  in  which  the  mouth  remains  open  continually,  in  which 
the  sets  of  teeth  stand  apart,  form  a  very  disagreeable  and  trou- 
blesome deformit3^  Many  people  cannot  bring  together  the 
anterior  portions  of  the  two  rows  of  teeth,  so  that  between  the 
upper  and  under  incisors  there  remains  a  space  from  two  to 
ten  millimetres  in  width.  This  space,  between  the  two  rows  of 
teeth,  gradually  becomes  smaller  from  before  backwards,  as  far 
as  the  second  molars,  the  masticating  surfaces  of  the  latter  being 
partly,  while  those  of  the  wisdom  teeth  are  wholly  in  contact 


IRREGULARITIES    OF    ARRANGEMENT.  Ill 

with  those  of  the  opposite  teeth.  This  repulsive  arrangement 
of  the  two  dental  arches  is  due,  generally,  to  a  short  articular 
process  of  the  lower  jaw,  as  a  result  of  which  the  anterior  seg- 
ment of  the  inferior  maxillary  arch  and  the  chin  assume  an 
unusually  depressed  position.  Less  frequently,  the  reason 
may  be  found  in  an  irregular  conformation  of  the  alveolar 
process,  the  posterior  alveoli  of  which  are  much  higher,  in- 
stead of  lower,  than  the  anterior  ones.  Still  more  rarely  is  it 
due  to  a  curve  or  an  oblique  direction  of  the  lower  jaw  from 
behind  forwards  and  dowuAvards.  It  might  be  attempted  also 
to  refer  this  deformity  to  the  crowns  of  the  last  molars,  but  as 
the  latter  are  always  found  unusually  low,  it  is  evident  that  the 
evil  will  not  be  remedied  by  filing  or  by  extracting  them. 

h.  C.  Langer*  mentions  a  form  of  want  of  relationship  between 
the  dental  rows  which  occur  in  giants  ;  the  jaws  are  developed 
in  height  nearly  in  proportion  to  the  rest  of  the  body,  and  the 
size  and  shape  of  the  lower  jaw,  especially,  assume  really  mon- 
strous proportions,  the  latter  exceeding  in  its  development  that 
of  the  upper  jaw  to  such  an  extent  that  its  dental  row  frequently 
forms  a  Avide  arch  which  envelops  that  of  the  latter.  The 
smaller  the  cranium  so  much  the  more  marked  is  this  monstrosity 
of  the  under  jaw. 

i.  In  cases  of  asymmetrical  development  of  the  two  halves 
of  the  same  jaw,  the  set  of  teeth  presents  a  distorted  appear- 
ance, and  projects  more  or  less,  either  obliquely  upwards  or 
downwards  upon  one  side  or  the  other. 

To  recapitulate,  the  irregular  (abnormal)  sets  comprise,  a, 
those  Avhich  are  flattened  in  front ;  h,  those  in  which  both  the 
upper  and  lower  ranges  project ;  c,  those  in  which  the  upper 
row  is  most  prominent;  f?,  those  in  which  the  lower  is  most 
prominent;  e,  the  upright  sets  ;  /,  those  in  which  both  rows  are 
inverted ;  g,  those  in  which  the  two  rows  are  separated  in  front ; 
7i,  those  in  which  the  lower  row  is  too  broad;  i,  the  distorted 
sets.  These  include  the  principal  forms,  between  which  innu- 
merable varieties  may  occur.  The  latter  are  the  more  frequent, 
since  complex  cases  occur  so  often,  Avhich  combine  irregularities 
in  the  position  of  the  entire  set  with  those  of  separate  teeth, 

*  Sitzungsber.  der  Wiener  Akad.  d.  Wiss.  vom,  1  Juii,  1869. 


112  PATHOLOGY. 

B.  Irregularities  in  the  Position  of  the  separate  Permanent 
Teeth. — The  irregularities  in  the  position  of  separate  teeth  may 
arise  from  several  causes  :  1.  From  the  growth  of  the  jaws  being 
absolutely  insufficient  in  proportion  to  the  space  required  in  the 
maxillary  segments  for  the  corresponding  teeth.  It  has  been 
shown  in  connection  with  the  growth  of  the  jaws,  that  the  an- 
terior portions  of  the  maxillary  arches  grow  comparatively  less 
than  the  branches  upon  either  side,  subsequent  to  the  eruption 
of  the  milk  teeth,  and,  therefore,  it  is  easy  to  understand  that 
irregularities  in  the  position  of  the  anterior  permanent  teeth 
are  of  more  frequent  occurrence;  2.  From  a  disproportion  be- 
tween the  very  wide  maxillary  segment  and  the  small  crowns  of 
the  teeth ;  3.  From  an  interruption  in  the  process  of  shedding 
the  teeth  ;  when  a  milk  tooth  is  retained,  the  corresponding  per- 
manent tooth  is  forced  to  take  another  position  ;  4.  From  an 
irregularity  in  the  process  of  shedding  the  teeth,  that  is,  when 
one  or  another  tooth  is  shed  and  replaced  prematurely,  the  adja- 
cent secondary  tooth  is  compelled  to  adopt  another  position; 
5.  From  the  early  removal  of  a  permanent  tooth,  in  which  case 
the  socket  cicatrizes  and,  consequently,  the  adjacent  permanent 
tooth,  which  has  not  yet  emerged,  is  compelled  to  assume  an- 
other position  ;  6.  From  the  existence  of  an  unabsorbed  alveolar 
cicatrix,  resulting  from  the  premature  shedding  or  extraction  of 
a  milk  tooth,  which  forces  the  secondary  tooth  to  take  another 
position  ;  7.  From  an  anomalous  position  of  the  milk  tooth,  which 
necessitates  an  irregular  position  of  the  permanent  tooth ;  8. 
From  the  partial  or  complete  occupation  of  the  place  of  a  per- 
manent by  a  supernumerary  tooth ;  9.  From  an  exostosis  upon 
the  alveolar  process,  especially  upon  its  posterior  segment ;  10. 
From  abscesses  of  the  alveoli  of  the  milk  teeth ;  11.  From  the 
presence  of  tumors  within  the  jaws,  collections  of  pus,  kc. 

Commonly  the  following  irregularities  are  presented  :  The 
long  diameter  of  the  tooth  is  inclined  too  much  externally  or 
internally  towards  the  median  line  of  the  jaw  or  laterally,  and 
frequently,  if  there  is  sufficient  space  to  allow  it,  the  tooth 
assumes  a  nearly  horizontal  position.  The  tooth  may  undergo 
a  quarter  or  half  revolution  upon  its  long  axis.  The  intervals 
between  certain   teeth  and  the  adjacent  ones  may  either  be  too 


IRREGULARITIES    OF    ARRANGEMENT.  113 

■wide  or  too  narrow,  and  in  the  latter  case  the  teeth  sometimes 
partially  overlap  their  neighbors  either  upon  the  facial  or  lin- 
gual surfaces. 

Central  Incisors. — A  slight  degree  of  irregularity  in  position 
is  presented  by  an  unusually  wide  separation  of  the  adjacent 
teeth,  which  occurs  less  frequently  with  the  lower  incisors. 
These  large  intervals,  which  frequently  amount  to  a  deformity, 
in  many  cases  are  occasioned  by  the  protracted  retention  of  a 
large  milk  incisor,  which  prevents  the  normal  emergence  and 
approximation  of  the  two  permanent  incisors.  Generally,  how- 
ever, they  are  due  to  the  firmness  of  the  suture  which  unites  the 
two  segments  of  the  upper  jaw. 

Twisting  of  the  central  incisors  upon  their  axes  is  by  no 
means  of  rare  occurrence.     This 

Fig.  32.* 

may  take  place  in  the  direction 
of  the  median  line  or  laterally, 
to  various  degrees,  45°,  90°,  and, 
in  rare  cases,  even  180°.  Ac- 
cording to  the  manner  and  extent 
of  the  revolution,  the  labial  sur- 
face becomes  turned  towards  the 
adjacent  central  or  lateral  incisor, 
and,  in   rare  cases,  it  is  changed 

so  as  to  look  towards  the  tongue.  The  torsion  is  generally  lim- 
ited to  one  central  incisor,  but  instances  are  recorded  in  which 
each  has  experienced  a  twisting  upon  its  axis  (Fig.  32). 

By  a  lateral  inclination  of  the  central  incisors  the  crowns  fre- 
quently overlap.  Sometimes  the  central  incisors  are  inserted 
more  or  less  towards  the  hard  palate,  or  the  lips.  In  many  cases 
one  of  them  stands  outside  the  range  anteriorly,  and  the  other 

*  Fig.  32  shows  a  twisting  of  both  central  upper  incisors,  occasioned, 
probably,  by  a  hyperostosis  in  the  palatal  suture.  The  labial  surfaces  of 
both  pormaiient  central  incisors  are  turned  laterally,  the  lingual  towards 
the  median  line  ;  the  lateral  milk  incisors  are  twisted  laterally  at  an  angle 
of  nearly  45° ;  the  milk  molars  are  in  their  normal  positions ;  the  first 
permanent  tooth  has  emerged.  The  maxillary  arch  is  narrow.  Natural  size. 
(From  a  plaster  cast,  for  the  use  of  which  the  author  is  indebted  to  Prof. 
Strasky.) 


114  PATHOLOGY. 

posteriorly,  so  that  the  loAver  incisors  are  inserted  between  the 
two  -when  the  jaws  are  closed.  The  upper  incisors  are  frequently 
inclined  posteriorly. 

The  causes  of  these  mal-positions  are  numerous.     The  reten- 
tion of  the  central  milk  incisor 
or  its  root,  the  premature  ap- 
pearance of  the  lateral  perma- 
nent incisor,  which  offers  an  im- 
pediment to  the  growing  tooth, 
1      or  perhaps  an  arrest  of  develop- 
J     ment  in  the  corresponding  por- 
j       I  I      L-^juiiA-iic^  tion    of   the  jaw,    or    a    super- 

^^         ^^  numerary  tooth  (Fig.  33),  may 

be  cited  as  predisposing  causes. 
As  the  tooth  during  its  growth  must  adapt  itself  to  the  space 
provided  for  it,  so  does  its  eruption  ensue  regularly,  or  a  mal- 
position occur  in  accordance  with  the  dimensions  of  the  space  it 
is  to  occupy. 

Lateral  Incisors. — The  axial  torsions  of  these  teeth  occur 
almost  always  in  such  a  manner  that  their  labial  surfaces  are 
turned,  to  a  slight  degree  only,  towards  the  median  line  of  the 
jaw,  or  laterally,  and  consequently  are  overlapped  by,  or  them- 
selves overlap,  the  lateral  borders  of  the  central  incisors. 

The  torsion  may  amount  to  90°,  and  in  rare  cases  it  reaches 
180°.     The  lower  laterals  are  more  frequently  the  subjects  of 
slight  rotations  than  the  upper  ones.     When  the  latter  are  in- 
volved, their  axes  are  directed  towards  the  canine  teeth  or  the 
'  central  incisors.     It  frequently  happens  that  they  are  implanted 


*  Fig.  33  shows  a  displacement  of  the  upper  front  teeth  on  the  right 
side,  produced  by  a  supernumerary  tooth.  The  front  teeth  upon  the  left 
side  of  the  broad  upper  jaw  were  quite  normally  arranged,  while  upon  the 
right  side  a  conical  supernumerary  tooth  (a)  occurred  within  the  dental 
range,  adjacent  to  the  left  central  incisor  ;  this  pressed  the  right  central  in- 
cisor [b)  forwards  and  upwards.  The  lateral  incisor  (c)  is  twisted  upon  its 
axis,  so  that  its  labial  surface  is  turned  laterally.  The  milk  canine  tooth 
{d)  is  retained,  and  the  permanent  one  [e)  is  implanted  without  the  dental 
range,  toward  the  face.  Natural  size.  (From  a  plaster  cast,  for  the  use  of 
which  the  author  is  indebted  to  Prof.  Strasky.) 


IRREGULARITIES    OF    ARRANGEMENT. 


115 


Fig.  34  * 


at  the  side  of  the  dental  range,  either  upon  the  facial  or  lingual 
side,  the  latter  nial-position  being 
most  marked  in  narrow  wedge-shaped 
upper  jaws.  In  the  latter,  which 
couinionly  are  asymmetrical,  the  lin- 
gual surfaces  of  the  central  incisors 
face  each  other,  and  the  lateral  in- 
cisors are  implanted  behind  the  den- 
tal range  at  a  greater  or  less  dis- 
tance from  the  palatal  suture  (Fig. 
34). 

Marked  mal-positions  of  the  front 
teeth  are  produced  very  often  by  the  presence  of  supernumerary 
teeth  in  the  anterior  portion 
of  the  upper  jaw,  since  the 
latter  are  the  first  to  make 
their  appearance  and  interfere 
with  the  eruption  of  the  nor- 
mal teeth  (Fig.  35). 

In  the  under  jaw  it  is  not 
uncommon  to  find  the  lateral 
incisors  implanted  upon  the 
lingual  side  of  the  dental 
range;  sometimes  they  stand 
directly  behind  the  central 
incisors  (Atlas,  Fig.  138),  and 


Fig.  35.t 


*  Fig.  34. — A  wedge-shaped  narrow  upper  jaw  of  a  young  person,  in 
which  both  lateral  incisors  have  emerged  upon  the  lingual  side  of  the  dental 
range,  in  consequence,  perhaps,  of  some  interruption  in  the  development  of 
the  jaw,  or,  it  may  be,  from  the  protracted  retention  of  the  lateral  milk  in- 
cisors. The  right  milk  canine  tooth  has  fallen  out.  (From  a  plaster  cast.) 
Two-thirds  natural  size. 

f  Fig.  35  shows  an  asymmetrical  conformation  of  the  upper  jaw  in 
which  two  supernumerary  teeth  are  implanted  behind  the  displaced  incisors. 
The  right  nuixillary  wall  bulges  forwards  in  front,  and,  between  the  first 
molar  («)  and  the  second  bicuspid  (6),  presents  a  flexion  towards  the  median 
line.  A  deviation  of  the  dental  arch,  therefore,  occurs  at  this  point,  and  the 
front  teeth  on  this  side,  the  canine  (c)  and  the  laterally  twisted  lateral  in- 
cisor, stand  in  a  straight  line.  The  central  incisor,  upon  the  right  side  (e), 
which  has  not  emerged  completely,  is  located  upon  the  median  line.     The 


116 


PATHOLOGY. 


Fl'i.  -Mk* 


at  other  times  they  present  a  combination  of  axial  torsion  and 
mesial  or  lateral  inclination  (Fig.  36). 

Probably    the   most  frequent   predisposing    causes   of   these 

irregularities  of  position  are  to  be 
found  in  the  development  of  the 
osseous  tissue  in  the  anterior  seg- 
ment of  the  jaw,  which  may  be  too 
slow  to  correspond  with  the  growth 
"^  of  the  permanent  teeth,  or  may  be 
arrested,  or  abnormal  in  its  dimen- 
sions. The  developing  crowns  will 
be  found,  even  within  the  dental  sacs,  in  abnormal  positions. 
A  protracted  retention  of  the  lateral  milk  incisors  or  canine 
teeth,  or  the  premature  cutting  of  the  permanent  canines,  may 
occasion  irregularities,  and  the  latter  may  crowd  the  lateral 
incisors,  before  they  are  properly  and  firmly  fixed,  towards  the 
median  line  of  the  jaw,  or  towards  the  tongue,  and  sometimes 
may  even  occasion  resorption  of  the  extremities  of  the  roots  of 
the  latter  teeth.  If  the  canine  tooth  emerges  upon  the  lingual 
side  of  the  dental  range,  it  may  press  the  lateral  incisor  towards 
the  lips. 

Canine  Teeth. — Irregularity  in  the  position  of  these,  especi- 
ally of  the  upper  ones,  occurs  frequently  ;  they  are  situated 
more  or  less  without  the  dental  range  and  overlap  the  lateral  in- 
cisor or  first  bicuspid,  either  upon  the  facial,  or,  more  rarely, 


left  central  incisor  is  implanted  upon  the  left  side,  and  the  left  lateral  incisor 
upon  the  lingual  side  of  the  left  canine  tooth  (/).  (From  a  plaster  cast.) 
Two-thirds  natural  size. 

*  Fig.  36. — Anterior  segment  of  the  lower  jaw.  View  from  the  lingual 
side.  The  two  lateral  incisors  are  implanted  behind  the  centrals,  are  twisted 
and  inclined  towards  the  median  line  of  the  jaw,  and,  together  with  the 
centrals  which  are  inclined  laterally  and  considerably  ■worn  away  upon 
their  coronal  edges,  inclose  a  quadrilateral  space.  As  the  lateral  incisors 
are  implanted  behind  the  dental  range,  and  their  edges  are  below  the  level 
of  the  masticating  teeth,  they  have  not  been  emploj'ed  in  mastication  and, 
indeed,  do  not  in  the  least  present  any  indications  of  abrasion.  These  irreg- 
ularities of  position  were  produced  by  an  interrupted  development  of  the 
jaw  and,  perhaps,  a  premature  eruption  of  the  canine  teeth,  which  are  very 
much  worn  away  upon  their  coronal  extremities.     Natural  size. 


IRREGULARITIES    OF    ARRANGEMENT. 


117 


upon  the  lingual  surface.  In  the  latter  case,  after  the  complete 
emergence  of  the  crown  of  the  canine  tooth,  there  occurs  an 
outward  displacement  of  the  lateral  incisor  or  first  bicuspid. 
The  inclination  of  the  axes  of  the  canines  usually  is  tow'ards 
the  median  line  of  the  jaw.  They  are  frequently  twisted  upon 
their  axes  to  a  slight  degree  and,  in  rare  cases,  present  quarter 
and  half  revolutions.  A  quarter  revolution  of  the  crown,  be- 
fore it  has  cut  through  the  gum  or  before  the  formation  of  the 
root  is  completed,  may  prevent  the  eruption  of  the  tooth,  since 
the  facio-lingual  diameter  of  the  crown  in  this  position  is  rela- 
tively too  great  to  enter  between  the  lateral  incisor  and  first 
bicuspid.  The  canine  tooth, 
therefore,    remains    concealed  ,        ^^^'"  ^'* 

'  b  a 

within  the  jaw,  on  account  of 
its  abnormal  torsion.  Some- 
times the  canine  tooth  aban- 
dons its  proper  place  entirely, 
and  is  found  by  the  side  of  the 
central  incisor  (Fig.  37),  in 
which  case  the  lateral  incisor 
is  located  either  upon  the  lin- 
gual or  lateral  side  of  the  displaced  canine  tooth, 
rarely,  the  canine  tooth  is  inserted  between  the  two  bicuspids. "f 
The  frequent  irregularities  in  the  position  of  canine  teeth 
may  readily  be  explained  when  we  consider  that  their  normal 
eruption  is  provided  for   by  the  vacant   spaces  which  remain 


Much  more 


*  Fig.  37  shows  a  displacement  of  the  upper  left  canine  («)  to  the  side  of 
the  central  incisor.  Posterior  to  the  former  is  an  alveolar  cicatrix,  prob- 
ably the  remains  of  the  socket  of  the  lateral  incisor  which  emerged  subse- 
quently to  the  canine.  Upon  the  right  side,  the  canine  occupies  its  normal 
position ;  the  lateral  incisor  (&)  is  stunted ;  the  bicuspids  upon  either  side 
retain  their  normal  positions.  IS'atural  size.  (For  the  use  of  this  specimen 
the  author  is  indebted  to  Dr.  Friedlowski.) 

■j-  The  museum  of  the  Harvard  Dental  School  contains  a  cast  taken  from 
the  mouth  of  a  young  woman,  in  which  the  left  inferior  lateral  incisor  and 
canine  are  transposed,  the  canine  being  turned  so  that  its  labial  surface  is 
presented  towards  the  central  incisor  and  the  median  line,  while  its  lingual 
surface  is  presented  towards  the  lateral  incisor  and  backwards. 

Another  cast  of  the  lower  jaw  of  a  person  about  sixteen  years  of  age  pre- 
sents the  canines  between  the  second  bicuspids  and  first  molars. — T.  B.  H. 


118 


PATHOLOGY. 


Fig.  38.* 


—  6 


between  the  first  bicuspids  and  lateral  incisors,  after  the  latter 
have  already  assumed  their  positions,  and  that  these  spaces  are 

too  narrow  when  the  growth 
of  the  jaw  in  length  is  sus- 
pended. A  premature  or  de- 
layed eruption  of  the  perma- 
nent canines,  a  protracted  re- 
tention of  the  milk  canines, 
sometimes  even  to  the  third 
decade  of  life,  or  the  inser- 
tion of  a  supernumerary  tooth 
in  the  dental  range,  may  also 
give  rise  to  these  displace- 
ments (Fig.  38). 
Bicuspids  and  Molars. — The  first  bicuspids  seldom,  the  second 
more  frequently,  are  met  with  without  the  dental  range  and 
generally  in  the  so-called  small  or  anterior  oval  cavity.  A  prem- 
ature loss  of  the  second  milk  molar  promotes  the  advance  of 
the  first  permanent  molar,  in  consequence  of  which  the  second 
permanent  bicuspid  is  forced  to  emerge  either  upon  the  facial 
or  lingual  side  of  the  dental  range.  In  many  cases,  one  or 
both  bicuspids  are  twisted  in  such  a  manner  that  their  cusps 
become  located  anteriorly  and  posteriorly,  instead  of  externally 
and  internally  (Fig.  39).  Insufficient  space  is,  almost  always, 
the  predisposing  cause. 


*  Fig.  38  shows  displacement  of  both  canines  produced  by  the  reten- 
tion of  the  milk  canines,  and  by  the  presence  of  a  supez'numerary  tooth. 
The  upper  jaw  is  broad  and  has  an  irregular  conformation.  The  central  in- 
cisors are  slightly  inclined  to  the  left  side,  where  the  milk  canine  [a),  worn 
away  by  attrition,  is  seen,  adjacent  to  the  central  incisor,  while  the  lateral 
is  located  upon  the  lingual  surface  behind  the  milk  canine  ;  the  permanent 
canine  (b)  is  in  the  dental  range,  in  front  of  the  first  bicuspid.  Upon  the 
right  side,  the  lateral  incisor  is  in  the  dental  range ;  the  permanent  canine  (c) 
is  inserted  without  the  dental  range,  towards  the  face;  the  milk  canine,  the 
crown  of  which  is  considerably  worn  away,  is  crowded  towards  the  tongue. 
Between  the  canine  and  the  first  bicuspid,  on  either  side,  is  a  supernumerary 
tooth  (rf),  the  crown  of  which  is  very  much  worn  away.  Behind  the  central 
incisors  are  seen  lunated  folds  of  mucous  membrane.  Two-thirds  natural 
size.  (From  a  plaster  cast,  for  the  use  of  which  the  author  is  indebted  to 
Prof.  Strasky.) 


IRREGULARITIES    OF    ARRANGEMENT. 


119 


Fig.  3!>.t 


An  axial  revolution  of   180°    is  extremely  rare.     AVerner* 
states  that  in  those  cases,  in  which  the  milk  molars  are  retained 
with  the  permanent  bicuspids,  the  latter  assume 
an  oblique  position.     J.  Tomes  observed  a  dis- 
placement of  the  bicuspids,  resulting  from  caries 
of  the  milk  molars,  which   was  followed  by  an 
alveolar  abscess,  and  also  axial  rotations  of  the 
second  bicuspids,  occasioned  by  the  retention  of 
the  palatal  root  of  the  second  milk  molar.    The 
lower  bicuspids   sometimes  stand  so  far  opart, 
in  consequence  of  the  great  abundance  of  room, 
that  a  person  unacquainted  with  the  true  condi- 
tion will  be  convinced  either  that  teeth  existed  previously,  or 
are  to  appear,  in  this  interspace. 

The  notable  derangement  which  supernumerary  teeth  occasion 
in  the  position  of  the  nor- 
mal teeth,  when  they  occur 
in  the  anterior  segments  of 
the  jaws,  may  also  extend 
so  far  as  to  involve  the  bi- 
cuspids, particularly  the  « 
second,  which  generally  in 
such  cases  are  implanted 
towards  the  tongue  (Fig. 
40). 


Fig.  40.t 


*  Anomalien  der  Zahnstellung.     Inauguraldissertation,  Giessen,  1868. 

f  Fig.  39  shows  a  segment  of  the  right  half  of  the  upper  jaw.  The 
two  bicuspids  are  placed  close  to  one  another  with  their  facial  surfaces 
twisted  posteriori}' about  90°  ;  the  first  is  crowded  somewhat  externally,  and 
is  in  contact  with  the  second,  which  is  pressed  slightly  towards  the  tongue. 
Natural  size. 

J  Fig.  40  shows  marked  displacement  of  the  upper  incisors,  canines,  and 
bicuspids,  occasioned  by  two  large  supernumeriiry  teeth.  The  two  central 
incisors  are  implanted  upon  the  lingual  side  of  the  dental  range,  the  left 
slightly  overlapping  the  right  in  front;  the  left  lateral  incisor  (a)  is  located 
outside  the  dental  range  towards  the  face;  behind  the  right  lateral  (b)  is 
located  the  first  bicuspid.  Two  conical  supernumerary  teeth  (c)  and  (d), 
which  are  worn  away  upon  the  crowns,  have  emerged  on  the  side  towards 
the  lips.  The  first  bicuspid  on  the  right  side  (e)  is  twisted  several  degrees 
towards  the  median  line  of  the  jaw,  the  second  is  inserted  upon  the  lingual 


120 


PATHOLOGY. 


An  arrest  of  development  in  the  posterior  segments  of  the 

jaws  sometimes  occasions  a  displace- 
ment of  the  three  molars,  by  which 
they  are  inserted  so  as  to  form  a 
triangle.  Wisdom  teeth,  especially 
those  in  the  under  jaw,  when  their 
roots  are  imbedded  in  the  coronoid 
process,  not  infrequently  are  in- 
clined anteriorly  to  a  considerable 
degree  towards  the  second  molars, 
with  the  posterior  coronal  surfaces 
of  which  their  masticating  surfaces 
come  in  contact.  Frequently  their 
crowns  present  a  lingual,  and, 
more  rarely,  a  facial  inclination. 
In  the  upper  jaw,  the  wisdom  teeth  are  inserted  sometimes  high 
up  towards  the  tuberosity,  'and  the  masticating  surfaces  may 
even  face  posteriorly.  Slight  displacements  of  these  teeth  with- 
out the  dental  range,  generally  to  the  lingual  side,  are  of  fre- 
quent occurrence. 

Marked  irregularities  in  the  position  of  the  molars,  accom- 
panied, at  times,  by  deformity  of  the  upper  jaw,  are  produced 
by  a  hyperostosis  upon  the  alveolar  process  (Fig.  41). f 


side  of  the  dental  range.  Upon  the  left  side,  the  bicuspids  are  separated 
somewhat  from  each  other  by  an  angular  interval  which  opens  externally, 
and  in  which  projects  the  coronal  portion  (/)  of  the  canine  tooth.  Two-thirds 
natural  size.  (From  a  plaster  cast,  for  the  use  of  which  the  author  is  in- 
debted to  Prof.  Strasky.) 

*  Fig.  41  shows  a  narrow  upper  jaw,  as  if  compressed  from  side  to  side. 
Plaster  cast.  The  six  front  teeth,  with  the  exception  of  the  left  lateral  inci- 
sor which  is  implanted  upon  the  lingual  side  of  the  dental  range,  are  ranged 
in  contiguity  so  as  to  form  a  very  narrow  arch,  the  arms  of  which  are  nearly 
parallel  to  each  other.  Three  molars  present  a  curved  arrangement  forwards 
and  outwards.  The  extremity  only  of  the  crown  of  the  first  right  molar  (?) 
has  emerged.  Distinct  folds  of  the  mucous  membrane  are  perceptible,  and 
also  hyperostoses  on  the  lingual  aspect  of  the  posterior  segments  of  the  al- 
veolar process,  which  diminish  the  breadth  of  the  channel-like  cavity  formed 
by  the  high  arch  of  the  hard  palate.     Two-thirds  natural  size. 

•f  In  the  Dental  Review  (1859),  a  curious  instance  is  mentioned  of  the  mal- 
position of  a  wisdom  tooth  between  the  upper  incisors.  A.  zur  Nedden 
(Deutsche  Viertelj.  f.  Z.,  18G8),  obtained  a  plaster  cast  of  an  upper  jaw  in 


IRREGULARITIES    OF    ARRANGEMENT.  121 

Irregularities  in  the  Position  of  Milk  Teeth. — The  milk  teeth 
are  very  rarely  met  with  without  the  dental  range,  and  only  in 
those  cases  in  which  all  the  milk  teeth  are  very  large,  when,  in 
consequence  of  a  deficiency  of  space,  the  incisors  overlap.  In 
many  cases  the  sharp  edges  of  the  upper  incisors  are  inclined 
very  much  towards  the  tongue,  and  the  canines,  uncommonly 
long  and  pointed,  are  crowded  towards  the  face. 

In  extremely  rachitic  individuals,  abnormal  positions  of  milk 
teeth  are  frequently  met  with,  since  in  these  cases  the  growth 
of  the  jaws  in  length  is  retarded  by  a  hj'perplasia  of  the  con- 
nective tissue  in  the  bone  (Atlas,  Figs.  144  and  145).  In  the 
latter  case,  moreover,  it  is  to  be  observed  that,  although  the 
process  of  decalcification  has  made  such  progress  in  the  bony 
structure  that  the  latter  has  become  flexible  and  may  be  cut 
with  a  knife,  it  has  not  in  the  least  affected  the  crowns  and  the 
growing  roots  of  the  teeth.  The  development  of  the  tooth,  there- 
fore, continues,  notwithstanding  the  notable  interruption  to  the 
growth  of  the  bone.  If  the  rachitis  does  not  become  very  de- 
cided until  after  the  milk  teeth  are  cut,  then  the  permanent 
teeth,  still  inclosed  in  the  dental  sacs,  may  be  displaced  from 
their  normal  positions. 

Abscesses  of  the  periosteum  of  the  root,  which  occur  particu- 
larly in  scrofulous  children  and  sometimes  after  cutaneous  erup- 
tions, may  produce  considerable  destruction  of  the  bone,  dis- 

which  a  molar  occupied  the  place  of  a  central  incisor,  neither  of  the  normal 
incisors  being  present. 

All  teeth  which  are  inserted  upon  one  side  of  the  dental  range,  or  overlap 
the  anterior  or  posterior  contiguous  teeth  either  upon  the  facial  or  lingual 
surface,  are  very  liable  to  be  atfected  with  caries,  because,  even  with  the 
utmost  cleanliness,  the  particles  of  food  cannot  be  removed  entirely  from 
the  intervals  between  the  teeth.  Moreover,  it  is  a  very  difficult  matter  to 
apply  to  them  the  ordinary  methods  of  treatment,  for  a  tooth,  which  is  in- 
serted externally,  cannot  be  reached  upon  the  inside,  and  one  situated  inter- 
nally cannot  be  reached  upon  the  outside,  on  account  of  the  close  proximity 
of  the  adjacent  tooth.  Therefore  they  require  peculiar  and  extremely  diffi- 
cult methods  of  treatment.  When  a  bicuspid  is  twisted  to  the  amount  of 
90°,  the  operative  treatment  is  attended  with  still  greater  difficulties,  because 
the  surfaces  of  its  roots  are  directed  outwards  and  inwards,  and  consequently 
offer  greater  resistance  by  reason  of  their  more  numerous  points  of  contact 
with  the  walls  of  the  alveolar  process; 


122  PATHOLOGY. 

placements  and  partial  destruction  of  the  milk  or  permanent 
teeth,  which  are  still  inclosed  in  the  dental  sac. 

C.  Irregularities  in  the  Position  of  Separate  Permanent 
Teeth  which  are  Imbedded  ivitlnn  the  Jaw. — It  sometimes  hap- 
pens that  a  tooth,  during  its  development,  acquires  a  more  or 
less  inclined  or  horizontal  position,  and  consequently,  when  its 
development  is  completed,  projects  but  little,  if  anj,  beyond  the 
alveolar  wall.  The  causes  of  these  extremely  curious  devia- 
tions of  position  can  be  ascertained  only  by  a  special  anatomical 
examination  of  each  individual  case.  As  a  general  rule,  it  may 
be  assumed  that  the  change  of  position  must  occur  prior  to  the 
development  of  the  root.  The  growth  of  the  latter,  modified  by 
the  local  relations,  takes  place  in  an  opposite  direction  to  that 
of  the  incisive  margin  or  masticating  surface  of  the  tooth  whose 
position  is  changed,  i.  e.,  if  the  masticating  surface  is  inclined 
forwards,  the  root  grows  from  before  backwards.  These  irregu- 
larities include  a  great  variety,  and  all  the  predisposing  causes 
which  have  been  mentioned  previously  are  equally  applicable  to 
them.  J.  Tomes*  illustrates  a  case  in  which  the  crown,  as  well 
as  the  root  of  the  right  central  incisor,  is  imbedded  in  an  oblique 
position  within  the  bone,  beneath  the  floor  of  the  nasal  cavity, 
its  normal  position  being  occupied  by  a  supernumerary  tooth, 
which,  it  is  obvious,  prevented  the  emergence  of  the  incisor. 

Figs.  2  and  3  of  the  Atlas  illustrate  a  case  in  which  a  well- 
formed  lateral  incisor  occupies  a  horizontal  position  in  the  angle 
formed  by  the  floor  of  the  antrum  and  the  nasal  process  of  the 
upper  jaw,  its  incisive  edge  projecting  through  an  oval  opening 
with  smooth  edges,  at  the  side  of  the  apertura  pyriformis.  The 
cause  of  this  displacement  is  obvious  in  the  presence  of  an  irregu- 
larly formed  tooth  Avhich  is  inclosed  in  a  smooth-walled  osseous 
capsule,  and  projects  near  the  edge  of  the  alveolar  process,  and, 
perhaps,  is  the  rudimentary  lateral  milk  incisor,  since  its  posi- 
tion is  directly  over  that  which  a  milk  incisor  should  occupy ; 
or  it  may  be  the  shapeless  mass  of  a  supernumerary  tooth. 

The  canine  teeth,  more  frequently  than  any  others,  are  the 
subjects  of  total  displacement,  a  fact  quite  easily  understood ; 
the  upper  canines  are  more  frequently  displaced  than  the  lower, 

*  System  of  Dental  Surgery,  p.  183. 


IRREGULARITIES    OF    ARRANGEMENT.  123 

as  the  front  teeth  of  the  upper  jaw  require  more  space.  Albinus* 
describes  a  case  with  a  canine  situated  between  the  nasal  cavity 
and  the  orbit  on  either  side,  whose  crowns  were  directed  upwards. 
J.  Hunterf  reports  a  similar  case.  Wait  observed  a  case  where 
the  radical  extremity  of  a  canine  pierced  the  gums  externally. 
J.  Tomes|  gives  a  series  of  illustrations  in  which  the  permanent 
canine  is  displaced  behind  the  dental  range,  the  root  being 
curved  very  much,  or  placed  across  the  dental  arch,  with  its 
apex  directed  towards  the  median  line  of  the  palate,  its  crown 
towards  the  cheek  and  projecting  slightly,  or  in  a  horizontal 
position,  with  the  coronal  apex  in  front  and  the  root  extending 
posteriorly  or  into  the  floor  of  the  nasal  cavity. 

The  succeeding  series  of  figures  will  serve  to  illustrate  the 
causes  of  partial  or  complete  perma- 
nent embedment  of  the  canine  teeth 
within  the  jaw.  In  the  case.  Fig.  42, 
the  retention  of  an  upper  milk  canine 
occasioned  a  twisting  of  the  croAvn  of 
the  permanent  tooth,  and  forced  it  to 
assume  an  oblique  position,  pointing 
towards  the  median  line,  so  that  its 
eruption  progressed  to  a  slight  degree  «=    " 

only  behind  the  dental  range. 

In  the  under  jaw  similar  conditions  are  met  with.  In  Fig. 
43  the  retained  milk  canine  tooth  produced  an  axial  revolution 
of  the  developing  crown  of  the  permanent  canine,  as  in  the  pre- 
ceding case,  and  has  inclined  it  towards  the  horizontal  line,  so 


*  Adnot.  Acad.,  i.  f  Nat.  Hist,  of  Teeth.  J  Op.  cit. 

§  Fig.  42  shows  the  incomplete  eruption,  upon  the  palatal  surface  of  the 
alveolar  process,  of  the  crown  of  the  right  upper  canine  which  has  an  oblique 
direction  towards  the  median  line.  (The  specimen  is  from  a  young  subject, 
and  for  the  use  of  it  the  author  is  indebted  to  Dr.  Friedlowsky.)  The  per- 
manent incisors  and  the  temporary  canine  have  been  detached  by  maceration. 
The  slightly  projecting  crown  of  the  permanent  canine  tooth  (a)  has  given 
rise  to  a  sharp-edged  opening,  the  result  of  absorption,  upon  the  alveolar 
process,  and,  in  the  same  manner,  the  corresponding  portion  of  the  alveolus 
of  the  lateral  incisor  (6),  and  also  that  of  the  milk  canine  (c),  has  been  ab- 
sorbed. The  first  bicuspid  was  slightly  twisted  by  the  curved  root  of  the 
permanent  canine  which  is  imbedded  within  the  jaw.     Natural  size. 


12-i  PATHOLOGY. 

that   its    extremity    only    has    emerged   beneath    the    alveolar 
margin. 

A  forward  inclination  and  quarter  revolution  on  the  part  of 
the  first  bicuspid  may  also  produce  an  axial  revolution  of  the 
growing  canine,  and  entirely  prevent  its  eruption  (Fig.  44). 

Fig.  43.* 


Goethe  observed!  in  an  osteological  preparation  in  the  pos- 
session of  Rapp,  in  Stuttgart,  1797,  a  total  displacement  of  a 
bicuspid  which  was  located  in  the  nasal  cavity  beneath  the 
margin  of  the  orbit,  its  roots  firmly  attached  to  a  small,  round, 
plaited  osseous    mass ;    it  extended    obliquely  downwards   and 

*  Fig.  43  shows  the  anterior  segment  of  the  lower  jaw  in  which  the  left 
canine  tooth  is  placed  horizontally  beneath  the  alveolar  margin.  The  coronal 
extremity  has  emerged  upon  the  lingual  wall  of  the  lower  jaw  (a).  The 
labial  surface  of  the  crown  is  upwards.  The  root  is  turned  obliquely  out- 
wards, projects  beyond  the  labial  wall  of  the  jaw,  and  has  given  rise  to  re- 
sorption in  the  corresponding  portion  of  the  wall  {b).  A  portion  of  the 
posterior  wall  of  the  alveolus  of  the  left  lateral  incisor  has  been  removed  by 
resorption  ;  the  superior  circumference  of  the  alveolus  of  the  milk  canine  (c) 
is  still  well  preserved.     Natural  size. 

f  Fig.  44  shows  a  segment  of  the  lower  jaw  from  which  a  portion  of  the 
facial  wall  was  removed  in  order  to  display  the  left  canine  and  first  bicuspid, 
which  are  not  yet  cut.  The  canine  remains  in  a  pez'pendicular  position,  and 
its  radical  extremity  (a)  reaches  to  the  inferior  border  of  the  lower  jaw;  its 
labial  surface  is  directed  forwards  and  inwards,  and  its  coronal  and  radical 
portions  are  in  contact  with  the  first  bicuspid  {b)  which,  also,  is  imbedded 
within  the  jaw,  its  internal  coronal  cusps  alone  being  slightlj-  exposed,  and 
is  inclined  anteriorly  and  twisted  on  its  axis  to  the  extent  of  a  quarter  of  a 
turn.  Natural  size, 
■j  Schweizerreise. 


IRREGULARITIES    OF    ARRANGEMENT.  125 

backwards,  and  emerged  from  the  palatal  portion  of  the  upper 
jaw  behind  the  incisive  canal,  where  its  crown  was  but  slightly 
exposed  upon  the  surface  of  the  palate.  J.  F.  Meckel*  met 
with  an  upper  second  bicuspid,  the  crown  of  which  pointed 
directly  upwards.  The  first  bicuspid  was  detached  at  an  early 
period,  and  there  was  a  large  gap  between  the  canine  and  first 
molar.  An  abscess  of  the  root- 
membrane  of  the  first  milk  molar  fig.  4.5.t 
may  have  given  rise  to  the  rota-  __,^-  j  t^gf/ 
tion  of  180°.  A  nearly  hori- 
zontal position  of  the  second  left 
bicuspid    in    the    upper  jaw,    as 

shown  in  Fig.  45,  in  all  proba-      f  £  j,^   j^^,^,^      ,^^ 
bility  was  occasioned  by  an  in- 
flammation of  the  periosteum  of 

the  root  of  the  first  molar,  which  was  followed  by  a  destruction 
of  the  corresponding  portion  of  the  alveolus  and,  without  doubt, 
occurred  at  an  early  period  while  the  process  of  shedding  the 
milk  molars  and  eruption  of  the  bicuspids  Avas  in  progress.  The 
cicatrization,  which  encroached  upon  the  territory  of  the  second 
permanent  bicuspid,  may  have  been  the  cause  of  the  deviation 
of  its  coronal  portion,  in  consequence  of  which  the  masticating 
surface  became  directed  backwards  and  slightly  downwards. 
The  tooth  emerged  in  the  gap  in  the  dental  row,  while  the 
growth  of  the  radical  portion  took  place  in  a  direction  forwards 
and  a  little  upwards.  By  the  removal  of  the  alveolar  wall  it 
was  ascertained,  further,  that  the  roots  of  the  first  and  second 
bicuspids  were  not  blended  together,  since  their  extremities  had 
been  kept  apart  by  a  thin  osseous  lamina. 

Abnormally  short  jaws  sometimes  contain  several  permanent 
teeth  imbedded  within  them  in  irregular  positions,  w^hich  do  not 


*  TabulsB  Anat.  Path.  Fasc,  iii. 

f  Fig.  45. — Facial  view  of  the  left  upper  jaw.  The  second  bicuspid  has 
a  nearly  horizontal  position,  its  masticating  surface  being  directed  towards 
the  anterior  facial  roots  of  the  second  molar ;  the  crown  and  neck  lie  in  the 
upper  part  of  the  alveolar  process,  within  an  excavation  which  probably 
resulted  from  an  alveolar  abscess  of  the  first  molar.  Two-thirds  natural 
size.    (For  the  use  of  this  specimen  the  author  is  indebted  to  Prof.  Langer.) 


126 


PATHOLOGY. 


make  their  appearance  until  tlie  occurrence  of  senile  atrophy  of 
the  alveolar  process,  and  then  only  partially  emerge  (Fig.  46). 


Fig.  40.* 


The  ivudom  teeth  are  more  frequently  the  subjects  of  a  total 
displacement.  The  reason  for  this  is  quite  obvious,  from  the 
fact  that  they  are  the  last  to  take  their  places  in  the  dental 
series  and  therefore  have  reserved  for  them  that  space  only 
which  remains  vacant  at  the  posterior  extremity  of  the  jaw.  In 
the  upper  jaw  an  axial  displacement,  by  which  the  masticating 
surface  becomes  directed  posteriorly,  is  the  most  frequent.  If 
the  coronal  portion  is  bent  from  its  normal  position,  so  as  to 


*  Fig.  46  shows  a  bicuspid  upon  the  right  and  left  side  imbedded  within 
the  short,  distorted  upper  jaw  of  an  old  person.  On  the  right  side,  behind 
the  alveolus  of  the  canine  tooth  (a),  the  alveolar  process  becomes  prominent 
and  presents  two  cavities,  at  the  bottom  of  which  are  seen  the  two  coronal 
cusps  of  a  bicuspid  (6),  with  the  longitudinal  groove  between  them  extending 
from  side  to  side.  Finally,  this  segment  of  the  jaw  also  presents  the  wisdom 
tooth  imbedded  within  the  maxillary  tuberosity  in  a  horizontal  position, 
with  its  crown  directed  posteriorly  and  its  roots  inserted  between  those  of 
the  second  molar,  as  may  be  seen  upon  the  buccal  surface  of  the  maxillary 
wall.  Upon  the  left  side  cicatrization  has  taken  place  in  all  the  alveoli. 
The  crown  of  the  bicuspid,  however,  which  is  imbedded  within  the  jaw  in 
an  oblique  position,  may  be  seen  through  the  openings  resulting  from  re- 
sorption in  the  bulging  portion  of  the  alveolar  process,  while  its  radical 
portion  (c)  forms  an  oblique  projection  upon  the  buccal  surface  of  the  jaw. 
The  lower  jaw  corresponds  to  that  of  extreme  old  age  and  is  edentulous, 
with  the  exception  of  one  bicuspid.  Natural  size.  (For  the  use  of  this 
specimen  the  author  is  indebted  to  Dr.  Friedlowski.) 


IRREGULARITIES    OF    ARRANGEMENT.  127 

describe  an  arc  of  90°,  the  growth  of  the  roots  takes  phice  from 
behind  forwards,  in  a  more  or  less  horizontal  direction,  and  the 
latter  come  in  contact  Avith  those  of  the  second  molar,  some- 
times even  blend  with  them,  so  that  the  second  and  third  molars, 
by  the  coalescence  of  their  roots,  form  an  inseparable  whole 
(Atlas,  Figs.  18  and  19).  If  now  the  growth  of  the  roots  of  the 
wisdom  tooth  continues  from  behind  forwards,  the  croAvn  neces- 
sarily emerges  posteriorly  and,  consequently,  induces  a  partial 
resorption,  varying  in  extent,  of  the  maxillary  tuberosity  of  tlie 
upper  jaw.  The  crown  of  the  wisdom  tooth  may  also  be  in- 
clined externally  or  internally,  and  the  roots  be  pLaced  across 
the  jaw  in  a  more  or  less  horizontal  position.  The  rotation 
sometimes  amounts  to  180°,  so  that  the  masticating  surface  is 
directed  upwards  and  the  roots  downwards. 

In  the  lower  jaAv,  an  inclination  of  the  crowns  of  the  wisdom 
teeth  from  behind  forAvards,  is  most  common,  in  Avhich  cases  the 
growth  of  the  roots  takes  place  in  the  ascending  ramus.  Wer- 
ner* also  mentions  cases  which  came  under  his  observation  where 
the  lower  wisdom  tooth  assumed  a  nearly  horizontal  position, 
the  roots  being  inclined  obliquely  dowuAvards  and  backwards, 
and  the  crown  forwards,  so  that  only  the  posterior  and  upper 
portion  of  the  crown  was  visible.  Sometimes  the  germ  of  the 
coronal  portion  of  this  tooth  is  displaced  so  far  posteriorly,  that 
the  crown  of  the  tooth  becomes  imbedded  within  the  ascending 
ramus  of  the  lower  jaw,  reaching  nearly  to  the  level  of  the  sig- 
moid notch.  Finally,  the  crown  of  the  wisdom  tooth  may  be 
the  subject  of  a  rotation  on  its  transverse  axis  to  the  extent  of 
180°,  in  which  case  the  inverted  crown  is  grasped  by  the  roots 
of  the  second  molar. f 

D.  Retention  of  Teeth  ivithout  Displaceme7it. — Cases  are  fre- 
quently met  Avith,  Avhere  completely  developed  permanent  teeth 
remain  during  life,  partially  or  entirely  inclosed  Avithin  the  jaAV, 
in  the  places  where  their  development  took  place.  The  position 
of  such  teeth  is  not  really  anomalous,  and  becomes  irregular 

*  Op.  cit. 

f  Compare  the  instructive  illustrations  given  by  J.  Tomes,  op.  cit.,  p.  192 
et  seq. 


128  PATHOLOGY. 

only  because  it  persists  during  the  later  periods  of  life.  Those 
teeth  are  most  frequently  the  subjects  of  this  irregularity,  which, 
as  their  growth  continues,  should  occupy  the  spaces  left  vacant 
by  the  already  developed  adjacent  teeth,  namely,  the  canines  and 
second  bicuspids.  The  canine  tooth,  as  we  know,  is  obliged  to 
insert  itself  between  the  permanent  lateral  incisor  and  first  bi- 
cuspid, after  the  latter  have  taken  their  positions  in  the  dental 
series,  and  the  second  bicuspid  enters  the  interval  left  vacant 
between  the  first  molar  and  the  first  permanent  bicuspid  which 
have  already  emerged.  If,  therefore,  from  any  cause  a  dispro- 
portion exists  between  the  above-mentioned  intervals  and  the 
circumference  of  the  crowns  of  the  teeth  which  are  to  occupy 
them,  the  complete  eruption  of  the  canine  or  second  bicuspid 
will  be  prevented  partially  or  entirely. 

An  instructive  case  is  illustrated  in  the  Atlas,  Fig.  4,  where 
both  canine  teeth  are  imbedded  within  the  lower  jaAv  and  are 
slightly  twisted  upon  their  axes,  the  right  towards  the  lateral  in- 
cisor and  median  line  of  the  jaw,  the  left  laterally  towards  the  first 
bicuspid.  The  development  of  the  radical  extremities  of  both 
canines,  in  the  direction  of  their  long  diameters,  was  possible 
only  to  a  certain  extent,  and  they  are  bent  at  nearly  right  angles, 
each  in  a  difi"erent  direction.  The  case,  therefore,  is  quite  com- 
plicated, as  it  illustrates  not  only  a  retention  of  both  canines 
within  the  under  jaw,  but  also  an  axial  revolution  and  a  deviation 
in  the  direction  of  growth  of  the  radical  extremities.  The  extent 
to  which  the  incisors  are  worn  away  indicates  that  the  specimen 
belonged  to  a  person  of  advanced  age,  and  so  it  may  be  assumed 
that,  had  all  the  adjacent  teeth  become  detached  and  an  atrophy 
of  the  alveolar  process  ensued,  the  coronal  extremities  of  both 
the  imbedded  canines  would  have  made  their  appearance.  Pos- 
sibly the  prolonged  retention  of  the  milk  canines  occasioned  the 
axial  revolution  of  the  permanent  teeth  and,  consecutively,  pre- 
vented the  eruption  of  the  latter,  but  this  point  cannot  be  de- 
termined. 

Wisdom  teeth,  especially  those  of  the  under  jaw,  are  most  fre- 
quently subject  to  retention.  The  space  necessary  for  their 
eruption  in  the  maxillary  arches,  which  so  frequently  do  not 
grow  to  a  suflScient  length,  is  preoccupied  by  the  teeth  which 


IRREGULARITIES    OF    ARRANGEMENT. 


129 


have  made  their  appearance,  and,  therefore,  there  is  no  room  left 
for  the  wisdom  teeth.  Sometimes  the  upper  second  molar  is' 
crowded  so  far  backwards  towards  the  tuberosity,  that  the  fur- 
ther descent  of  the  third  becomes  impossible.  In  the  same  way, 
the  space  in  the  lower  jaw  becomes  diminished  when  the  second 
molar  is  crowded  close  up  to  the  ascending  ramus.  In  addition 
to  the  disproportion  between  the  lengths  of  the  maxillary  and 
dental  arches,  special  causes,  which  are  not  readily  distinguish- 
able, also  occasion  the  retention  of  the  wisdom  teeth.  Some- 
times, during  the  process  of  cicatrization  which  ensues  after  the 
detachment  of  the  first  upper  molar,  the  second  molar  acquires 
a  forward  inclination  which  prevents  the  emergence  of  the  wis- 
dom tooth,  since  the  posterior  external  root  of  the  former  im- 
pinges upon  and  opposes  the  advance  of  the  crown  of  the  latter 
(Fig.  47). 

b  Fig.  47.*  Fig.  48.t  Fig.  49.t 


*  Fig.  47  show.s  an  obstacle  to  the  descent  of  the  right  upper  wisdom  tooth, 
in  a  facial  view  of  the  posterior  segment  of  the  upper  jaw.  The  first  molar 
was  detached  some  time  previously  ;  the  second  is  inclined  anteriorly,  and 
the  extremity  of  the  posterior  facial  root  (a)  has  a  corresponding  deviation 
posteriorly,  and  presses  against  the  descending  masticating  surface  of  the 
wisdom  tooth,  the  facial  surface  of  which  {b)  has  been  exposed  by  the  removal 
of  the  alveolar  wall.     Two-thirds  natural  size. 

f  Fig.  48  shows  the  union  of  the  roots  of  the  upper  second  molar  on 
the  leftside,  with  those  of  the  wisdom  tooth,  as  seen  from  the  facial  side. 
The  posterior  facial  root  of  the  second  molar,  which  has  been  filed  away  to 
show  the  root  canal,  impinges  upon  the  anterior  facial  root  of  the  wisdom 
tooth,  and  is  united  to  it  hy  means  of  cement;  in  the  same  manner,  the 
lingual  root  of  the  second  molar  is  united  with  the  anterior  facial  root  of  the 
wisdom  tooth  by  means  of  a  quite  thick  layer  of  cement.  These  teeth  were 
extracted  on  account  of  chronic  inflammation  of  the  root-membrane  and 
suppuration  of  the  gum.  Natural  size.  (For  the  use  of  this  specimen  the 
author  is  indebted  to  Dr.  Jurie  Gustav.) 

J  Fig.  49  shows  a  union  of  the  posterior  facial  root  of  the  upper  second 

9 


130  PATHOLOGY. 

Sometimes  a  union  of  the  roots  of  the  second  upper  molar 
with  those  of  the  -wisdom  tooth,  also,  prevents  the  descent  of  the 
latter.  In  such  cases  the  wisdom  teeth  are  found  in  a  normal 
position,  but  are  situated  one  centimetre  higher  than  usual  (Figs. 
48  and  49). 

Teeth  which  are  retained  within  the  jaw  frequently  make 
their  appearance  unchanged  in  the  later  periods  of  life,  when 
their  emergence  is  promoted  by  the  loss  of  the  other  teeth  and 
by  the  changes  which  take  place  in  the  jaws  in  old  age.  People 
who  are  ignorant  of  this  fact  interpret  the  occurrence  falsely 
as  an  evidence  of  remarkable  vigor,  when,  in  reality,  it  is  only 
an  indication  of  old  age.  These  teeth  always  emerge  very 
slowly,  and  are  rarely  of  much  value  to  the  possessor. 

4.  Irregularities  of  Structure. 

These  involve  either  all  the  teeth  in  common,  or  a  part  of  them, 
most  frequently,  however,  separate  teeth  or  only  their  coronal 
or  radical  portions.  In  general  terms,  they  comprise  growth  in 
an  abnormal  direction ;  excessive,  stunted,  or  arrested  develop- 
ment of  the  dental  tissues  ;  the  coalescence  of  two  dental  germs 
and  the  blending  of  roots;  monstrous  malformations  of  the 
crowns  and  roots,  and  double  malformations  of  the  teeth. 

a.  Flexions  and  Torsions  of  the  Crowns  and  Roots. — In  rare 
cases,  teeth  which  have  single  roots  are  bent  at  right  or  more 
obtuse  angles  in  the  coronal  portions  or  in  their  immediate 
vicinity,  while  the  roots,  in  these  cases  frequently  stunted, 
retain  their  normal  positions.  With  the  crowns  of  incisors,  rec- 
tangular flexions  are  most  frequently  observed,  their  incisive 
edges  being  directed  forwards  or  backwards,  or  inclined  to  either 
side.  When  the  crown  of  an  upper  incisor  is  bent  towards  the 
lips,  the  palatal  surface  of  the  tooth  is  directed  downwards,  and 
upwards  Avhen  the  flexion  is  towards  the  tongue.  The  reverse 
is  the  case  with  the  incisors  of  the  lower  jaw. 

molar  on  the  left  side  with  the  blended  facial  roots  of  the  wisdom  tooth. 
View  from  the  facial  side.  Natural  size.  (For  the  use  of  this  specimen  the 
author  is  indebted  to  Dr.  Friodlowski.) 


IRREGULARITIES    OF    STRUCTURE.  131 

The  development  of  a  crown  which  is  the  subject  of  this  dis- 
tortion may  go  on  to  completion ;  exami- 
nation of  the  enamel,  however,  in  the  vi-  ^^' '__  ^"' ''  ' 
cinitj  of  its  terminal  portions,  will  show 
a  variation  from  the  normal  arrangement 
of  the  layers,  inasmuch  as  the  enamel  is 
thicker  at  the  vertex  of  the  angle  of  flexion, 
while  the  margin  of  the  enamel  is  furrowed 

in  some  cases,  and  raised  into  a  fold  in  others  (Figs.  50  and  51). 
Sometimes  cleft-like  gaps,  lined  with  very  thin  layers  of  enamel, 
are  met  with,  which  likewise  indicate  irregularity  and  interrup- 
tion in  the  development  of  the  enamel.  These  circumstances 
justify  the  assumption  that  the  flexion  takes  place  prior  to  the 
completion  of  the  formation  of  the  enamel  cap  of  the  crown. 
The  growth  of  the  roots  may  continue  in  the  normal  direction 
after  the  occurrence  of  flexion  of  the  coronal  portions. 

These  flexions  should  be  studied  carefully  by  practitioners  to 
whom  such  teeth  are  presented  for  the  purpose  of  being  straight- 
ened, because  the  distortion  can  neither  be  removed  nor  im- 
proved, and  there  is  nothing  to  be  done  except  to  extract  the 
tooth  affected.  Care  should  be  taken  not  to  confound  cases 
presenting  this  deformity  with  those  in  which  normally  formed 
teeth  assume  an  oblique  or  a  nearly  horizontal  position,  and 
which,  under  favorable  circumstances,  may  be  treated  with  suc- 
cess. A  careful  examination  of  the  teeth  and  jaws,  and  par- 
ticularly the  existence  of  slight  irregularities  upon  the  crown  of 
the  tooth  in  question,  for  example,  notable  bulging  upon  either 

*  Fig.  50. — Lateral  view  of  an  upper  central  incisor.  The  crown  is  com- 
pletely developed  ;  the  extremity  of  the  short,  thick  root  is  turned  towards 
the  lips.  On  the  edge  of  the  enamel,  on  the  lingual  surface,  rises  a  sharp 
ridge,  corresponding  to  which,  upon  the  labial  surface,  is  a  constriction. 
Natural  size. 

t  Fig.  51. — Lateral  view  of  a  lower  central  incisor.  The  crown  is  bent 
at  a  right  angle,  so  that  the  incisive  edge,  with  its  three  denticles,  is  directed 
towards  the  lips.  The  lingual  surface  is  turned  obliquely  upwards.  In  the 
vicinity  of  the  neck  of  the  tooth,  at  the  part  corresponding  to  the  vertex  of 
the  angle  of  the  flexion,  a  distinct  layer  of  enamel  is  presented,  which  resem- 
bles a  flattened  nodule  and,  when  examined  with  a  lens,  seems  to  be  sepa- 
rated from  the  enamel  of  the  crown  by  a  narrow  zone  of  dentine.  Natural 
fcize. 


132  PATHOLOGY. 

surface  of  the  horizontally  placed  crowns,  a  very  narrow  neck, 
and  a  marked  mobility  of  the  tooth  under  slight  pressure,  will 
indicate,  with  a  considerable  degree  of  probability,  the  existence 
of  a  flexion  of  the  crown  at  an  angle  with  the  root. 

Flexions  of  the  roots  are  met  with  near  the  necks,  in  the 
middle  portions,  or  at  the  extremities,  and 
Fig.  52.=^  Fio.  53.t  are  of  various  dcgrecs.  Those  of  a  moderate 
degree  are  limited  to  a  slight  S-shaped 
curvature ;  those  of  a  higher  degree  present 
a  step-like  deviation  (Atlas,  Fig.  7),  or  a 
sharply  defined  bend  of  the  axis  of  the  tooth 
(Fig.  52).  Flexions  at  the  extremities  are 
the  most  common,  and  are  single,  double, 
or  zigzag  (Fig.  53). 

The  pulp-cavity  is  inclined  in  correspondence  with  the  flexion 
of  the  crown,  and  the  root-canal,  in  conformity  to  the  flexion  of 
the  roots,  presents  one  or  two  deviations  from  the  straight 
course.  The  continuity  of  the  dentine  is  uninterrupted,  as  its 
canals  adapt  themselves  to  the  direction  of  the  deviating  portion. 
Axial  torsions  of  the  crowns  present  an  appearance  such  as 
would  be  produced  by  twisting  the  coronal  portion  about  its 
axis,  so  that  the  corresponding  surfaces  of  the  crown  and  root 
do  not  lie  in  the  same  planes.  Such  irregularities  of  formation 
are  met  with  only  in  teeth  with  single  roots,  particularly  in 
canine  teeth,  but  also  in  bicuspids.  They  are  twisted  from  90° 
to  180°,  so  that  the  facial  surface  of  the  crown  is  turned  towards 
the  tongue,  which,  however,  does  not  prevent  the  root  from  re- 
taining its  normal  position.  Deficiency  of  space,  at  the  time 
when  the  crown  is  just  formed,  may,  with  reason,  be  assumed  to 
be  the  cause  of  this  phenomenon,  while,  during  the  subsequent 
expansion  of  the  contracted  space,  the  root  would  be  enabled  to 
develop  in  its  normal  position.  Similar  circumstances,  namely, 
the  adaptation  of  the  growth  of  the  root  to  the  varying  space 

*  Fig.  52. — Lateral  view  of  a  central  upper  incisor,  which  presents  a 
sharply-defined  flexion  in  the  upper  half  of  the  root.     Natural  size. 

f  Fig.  53. — Lateral  view  of  an  upper  central  incisor,  which  presents  a 
double  flexion  towards  the  extremity  of  the  root.     Natural  size. 


IRREGULARITIES    OF    STRUCTURE.  133 

provided  for  the  latter,  may  also  be  the  cause  of  the  spiral 
twisting  of  roots  which  is  met  with. 

From  the  appearances  which  are  found  upon  the  bent  crowns 
and  roots,  there  can  be  no  doubt  that  the  direction  of  growth  of 
the  tooth  may  be  altered  by  external  influences,  and  in  the  fol- 
lowing manner :  either  the  crown  undergoes  a  more  or  less  dis- 
tinct deviation  in  the  direction  of  its  growth,  prior  to  the  comple- 
tion of  its  development,  or  a  deviation  takes  place  subsequently, 
in  which  case  it  occurs  at  the  neck,  or  in  the  vicinity  of  the 
middle  or  the  extremity  of  the  root.  The  process  may  be  con- 
ceived of  as  occurring  in  the  following  manner.  The  develop- 
ment of  the  formative  cells  of  the  enamel,  upon  the  surface  of 
the  enamel  organ,  is  arrested  in  some  parts  by  external  influ- 
ences, while,  in  others,  a  proliferation  of  the  cells  ensues.  Simi- 
lar influences  induce  a  variation  in  the  arrangement  of  the  den- 
tinal cells  which  become  inclined  in  one  or  another  direction. 

J.  Tomes*  first  directed  attention  to  that  remarkable  irregu- 
larity of  formation,  which  he  describes  as  "  dilaceration  of  par- 
tially-developed teeth  from  the  formative  pulp,"  and  considers 
it  to  be  the  result  of  a  forcible  displacement  of  the  cap  of 
developed  dentine  from  the  pulp,  the  development  of  the  dentine 
being  continued  in  this  abnormal  position.  That  the  incisors 
and  bicuspids  are  the  subjects  of  dilaceration,  he  explains  by  the 
fact  that  they  are  more  exposed  to  accidental  influences. 

In  many  cases,  external  mechanical  influences  apparently  do 
give  rise  to  flexion  of  a  tooth  during  its  formation ;  in  such 
instances,  however,  sufficient  evidence  must  be  adduced  to  show 
that  the  blow  or  kick,  and  the  like,  really  occurred  during  the 
process  of  formation  of  the  tooth.  Generally,  however,  patients 
are  unable  to  recall  any  such  occurrences,  which  may  have  been 
mechanical  causes ;  indeed  such  a  cause  often  is  not  in  the  least 
to  be  thought  of  in  cases  in  which  the  bent  crown  has  emerged 
only  partially  or  not  any.  Evidently,  also,  dilaceration,  resulting 
from  a  kick,  blow,  or  fall,  could  not  have  been  intended  in  the 
sense  that  portions  of  the  soft  dental  tissues  are  ruptured ;  in 
that  case  a  circumscribed  cicatricial  tissue  could  be  demonstrated, 


*  Lectures  upon  Dental  Phys.  and  Surgery,  and  System  of  Dental  Surgery. 


134  PATHOLOGY. 

which,  however,  is  not  the  fact,  for  only  a  displacement  of  the 
dental  tissues  is  met  with.  With  this  view  of  the  subject  the 
term  "  dilaceration"  was  not  well  chosen. 

In  particular  cases  it  is  quite  possible  that  continued  pressure 
of  a  tooth  already  cut  upon  one  whose  development  is  interrupted, 
or  whose  eruption  is  retarded,  may  give  rise  to  a  flexion  or  dis- 
placement of  the  coronal  portion.  The  singular  fact,  that  up  to 
the  present  time  these  coronal  flexions  have  been  observed  only 
in  teeth  with  single  roots,  cannot  be  satisfactorily  explained. 

Flexions,  at  the  commencement,  in  the  middle  or  at  the  ex- 
tremity of  roots,  evidently  cannot  be  caused  by  any  accidental 
external  influences,  but  always  are  induced  by  the  contracted 
proportions  of  the  space  provided  for  them,  of  which  mention 
has  been  made.  In  many  cases  a  want  of  proportion  between 
the  depth  of  the  jaw  and  the  length  of  the  root  gives  rise  to  a 
flexion,  as  also  may  the  retarded  eruption  of  a  tooth,  which 
compels  the  root,  as  its  growth  continues,  to  turn  off"  at  an  angle. 
The  facial  or  lingual  wall,  especially  of  the  under  jaw,  may  also 
exert  an  influence,  if  the  roots,  growing  in  an  irregular  direction, 
strike  against  the  wall. 

Flexions  of  the  crown  or  neck  have  a  deceptive  resemblance 
to  a  united  fracture  of  a  tooth,  and  have  been  regarded  as  such, 
as  in  the  case  described  by  H.  Hertz  ;*  but  the  principal  evidence 
in  proof  of  the  occurrence  of  a  fracture,  the  formation  of  a  callus, 
is  wanting  in  these  cases. f 

h.  Excessive  Growth  upon  the  Crowns  and  Roots. — The  lesser 
irregularities  coming  under  this  head  comprise  chiefly  the  so- 
called  enamel  nodules^  which  are  of  small  size  and,  also,  occur  in 
particular  localities.  Most  of  them  are  hemispherical  superficial 
growths,  varying  in  size  between  diminutive  nodules  barely 
visible  to  the  naked  eye  and  those  two  to  four  millimetres  in 
diameter.  They  are  located  upon  the  necks  of  teeth  with  mul- 
tiple roots,  at  a  slight  distance  from  the  boundary  of  the  enamel, 
or  even  upon  or  between  the  roots  (Atlas,  Figs.  23,  25,  and  26). 
They  have  a  white,  polished,  pearly,  clear,  rounded  appearance, 

*  Virchow's  Archiv,  Bd.  38. 

f  C.  "Wedl,  uber  Knickungen  und  Drehuiigen  an  den  Kronen  und 
Wurzeln  der  Zahne,  Deutsche  Viertelj.  f.  Z.,  1867. 


IRREGULARITIES    OF    STRUCTURE.  135 

always  are  attached  by  the  flat  surface  of  the  spherical  segment, 
and,  not  infrequently,  are  united  with  the  zone  of  the  enamel 
by  a  narrow,  spinous,  sharp  lamina.  Heider  and  I,  up  to  the 
present  time,  have  observed  well-formed  enamel  nodules  only 
upon  the  molars  of  the  upper  ja'w;  and  have  never  met  with 
them  upon  teeth  with  single  roots,  but  J,  Tomes*  gives  an 
illustration  of  a  case  in  which  a  large  nodule  of  enamel  is  at- 
tached to  the  neck  of  a  tooth  with  a  single  root. 

Occasionally  ridges  of  enamel  are  met  with  on  the  molars  of 
the  lower  jaw,  which,  commencing  at  the  boundary  of  the  enamel 
on  the  neck  of  the  tooth,  are  prolonged  directly  between  the 
anterior  and  posterior  roots,  but  without  forming  nodular  en- 
largements. 

Although  these  enamel  nodules  are  of  rare  occurrence,  still 
they  are  more  common  than  is  supposed,  since,  on  account  of 
their  unusually  small  size,  they  are  liable  to  escape  observation 
on  teeth  which  have  just  been  extracted  and  are  covered  with 
blood.  It  is  obvious,  that  the  nodules  or  ridges  which  are  met 
with  upon  the  molars  are  the  results  of  localized  continuations 
of  the  development  of  the  enamel  between  the  already  devel- 
oped basal  portions  of  the  roots,  and  are  produced  by  the  strip 
of  the  enamel  organ  which  has  persisted  longer  than  the  rest. 

If  a  section  be  made  through  an  enamel  nodule,  it  will  be 
found  that  the  enamel  forms  a  thick  layer  upon  a  truncated 
cone  of  dentine  (x\tlas,  Fig.  24).  In  many  nodules,  cross-sec- 
tions of  the  enamel  have  a  light  color  and  indicate  a  normal 
formation,  while  others  present  an  abundant  deposit  of  pigment 
and  an  irregular  arrangement  of  the  prisms.  The  dentinal 
cone  is  a  direct  prolongation  from  the  dentine  of  the  neck  or 
root,  and  contains  dentinal  canals  which  assume  a  regular  ar- 
rangement and  a  radiating  course.  Occasionally  one  or  more 
empty  spaces  or  cavities  are  met  with  which  are  filled  with  mi- 
nute granules  of  calcareous  salts. 

With  reference  to  their  structure,  the  enamel  nodules  are  to 
be  reo-arded  as  lateral  offshoots  from  the  teeth,  and  are  to  be 
classed  with  the  small  dentiform  excrescences  which  are  met 

*  System  of  Dental  Surgery,  Fig.  102. 


136  PATHOLOGY. 

witli,  sometimes,  upon  the  facial  or  lingual  surfaces  of  the  molars, 
especially  those  of  the  lower  jaw.  In  many  cases,  particularly 
upon  the  upper  milk  molars,  a  cusp,  covered  with  enamel,  is 
met  with  upon  the  lingual  aspect  of  the  neck,  the  apex  of  which 
projects  through  the  gum  as  if  it  were  isolated,  and  may  lead 
to  the  false  supposition  that  it  is  a  new  tooth  which  is  just 
emerging. 

An  excess  in  the  number  of  roots  is  not  uncommon.  Super- 
numerary roots  sometimes  are  stunted  in  their  growth,  at  others, 
they  are  completely  developed,  and  occur  either  in  the  form  of 
lateral  offshoots,  or  are  produced  by  a  division  of  the  flattened 
roots,  as  is  the  case,  particularly,  Avith  the  lower  incisors  and 
canines  (Fig.  54),  the  upper  bicuspids,  and  upper  and  lower 
molars. 

It  is  very  uncommon  to  find  two  completely  separate  roots 
upon  the  upper  incisors  and  canines,  or  upon  the  lower  bicuspids, 
that  is  to  say,  upon  the  teeth  which  properly  have,  single,  con- 
ical roots  (Fig.  55).  A  partial  division  at  the  radical  extremity 
of  a  lower  bicuspid  is  extremely  rare.  Supplemental  roots, 
consisting  of  lateral  offshoots  which  are  located  in  the  region 
of  the  neck  of  the  tooth  and  attain  scarcely  one-third  the 
length  of  the  normal  root,  are  met  with,  though  rarely  (Figs. 
56  and  57). 

Roots  which  arise  from  a  division  are  always  conical,  in  other 
words,  cross-sections  of  them  are  circular. 

Carabelli*  observed  an  extremely  rare  case,  in  which  all  the 
bicuspids  of  a  skull  had  three  roots.  The  upper  ones  were  seen 
to  possess  three  entirely  distinct  roots,  and  the  existence  of  the 
same  number  upon  those  of  the  lower  jaw  was  indicated  by 
deep  depressions  corresponding  to  them.  Bicuspids,  first  ones 
especially,  with  three  roots,  are  frequently  met  with,  in  which 
cases  the  arrangement  of  the  roots  is  similar  to  that  of  the 
roots  of  the  molars,  but  they  stand  close  to  one  another,  so  that 
the  teeth  are  more  easily  extracted  (Fig.  58).  Sometimes  the 
upper  bicuspids  have  two  separate,  divergent  roots  (Atlas,  Fig. 
6) ;  the   divergence,  in   some  cases,  being  so  great,  that  ex- 

*  Anatomie  des  Mundes. 


IRREGULARITIES    OP    STRUCTURE. 


137 


traction  of  the  teeth  is  accomplished  very  seldom  without  frac- 
ture of  one  of  the  roots. 

The  occurrence  of  upper  molars  with  five,  and  lower  ones 


Fig.  54* 


Fig.  55.t 


Fig.  .'^6.+ 


Fig.  57.§ 


Fig.  58. [| 


with  four  roots  is  accounted  for  by  a  division  of  all  the  flattened 
roots  belonging  to  them.  When  the  upper  molars  have  four 
regularly  formed  roots,  the  two  flattened  ones,  as  is  the  case 
normally,  are  placed  upon  the  outside,  and  the  rounded  ones, 
opposite  the  first,  upon  the  inside.  Consequently  the  second 
internal  root  is  to  be  regarded  rather  as  a  supplemental  one, 
that  is  to  say,  not  the  result  of  a  division. 

Sometimes  all  the  lower  molars  have  a  third  root  which  is 
roundish  and  located  internally,  towards  the  cavity  of  the 
mouth.  It  gives  to  the  lower  molar  a  form  similar  to  that  of 
an  upper  and  might,  therefore,  lead  to  a  confounding  of  the  two ; 
but  they  may  be  distinguished  by  the  fact  that,  in  the  lower 
molar,  this  third  root  always  arises  from  the  inner  surface  of 


*  Fig.  54  shows  a  longitudinal  section  of  a  canine,  with  two  root-canals 
in  the  divided  root.  Canines  are  also  met  with,  in  which  a  single  root  pre- 
sents two  root-canals.     Natural  size. 

t  Fig.  55  shows  a  lower  bicuspid  with  two  hroad  roots :  the  latter  are 
of  equal  length,  separate,  flattened,  and  marked  by  a  shallow  groove. 
Natural  size. 

J  Fig.  56  shows  an  upper  central  incisor  with  a  short,  conical  supple- 
mental root,  arising  from  the  neck  of  the  tooth.  View  of  the  labial  surface. 
Natural  size. 

§  Fig.  57  shows  a  much  worn  lower  incisor,  the  lingual  surface  of 
which  is  bevelled,  and  upon  its  neck  is  located  a  short,  conical,  supplemental 
root.     Natural  size. 

II  Fig.  58  shows  the  anterior  surface  of  an  upper  bicuspid,  with  three 
distinct,  slightly  divergent  roots,  and  a  normally  formed  crown.  Natural 
size. 


138  PATHOLOGY. 

the  base  of  the  posterior  root,  and  never  from  the  middle  por- 
tion of  the  neck  of  the  tooth,  as  is  the  ease  with  the  rounded 
root  of  the  upper  molar.  Five  entirely  separate,  completely 
formed  roots  also  are  met  with  (Atlas,  Fig.  11),  in  which  cases, 
the  fifth,  which  is  located  upon  the  lingual  side,  is  not  the  result 
of  a  division  into  three  roots,  but  is  a  supplemental  formation. 
Both  upper  and  lower  molars  with  more  than  five  roots  have 
also  been  observed,  but  such  cases,  it  is  evident,  are  the  result 
of  the  union  of  two  molars. 

Under  the  head  of  excessive  formations  are  also  to  be  con- 
sidered the  unusually  long  or  thick  7'oots,  as  well  as,  in  most 
cases  at  least,  the  unusually  divergent  or  curved  roots,  and 
finally  the  condyloid  or  nodular  enlargements,  which  are  met 
with  at  the  extremities  of  roots  and  are  not  to  be  confounded 
with  hypertrophy  of  the  cement. 

The  length  of  the  roots  may  be  excessive  either  absolutely  or 
relatively,  i.  e.,  in  proportion  to  the  depth  and  thickness  of  the 
jaw.  In  some  cases,  the  second  bicuspids,  or  the  first  and  second 
molars,  are  inserted  to  an  unusual  depth  into  the  floor  of  the 
antrum  of  Highmore,  where  they  form  hump-like  prominences, 
and  their  extraction  is  likely  to  occasion  quite  serious  injuries. 

The  three  roots  of  the  upper  molars  frequently  present  an 
excessive  thickness  and  divergence.  Sometimes  the  roots  of 
the  lower  molars  are  very  broad,  and  separated  by  unusually 
wide  intervals.  The  extraction  of  the  latter  teeth  is  the  more 
difficult  when  the  two  adjacent  teeth  are  still  present  in  the  jaw. 
It  is  not  uncommon,  in  teeth  with  several  roots,  to  find  that  the 
development  of  the  latter,  in  respect  of  size,  is  in  an  inverse 
proportion,  i.  e.,  if  the  internal  ones  are  well  developed,  the  two 
outer  ones  are  found  to  be  stunted,  and  vice  versa. 

Curves  of  all  or  of  separate  roots,  which  are  absolutely  or 
relatively  too  long,  occur  in  every  conceivable  form,  and  a 
knowledge  of  them  is  of  special  interest  to  the  practitioner, 
since  very  slight  deviations  may  be  important  obstacles  in  the 
way  of  extraction.  For  a  long  time,  therefore,  practitioners 
have  devoted  their  attention  to  these  curves  of  the  roots,  and 
the  student  will  find  in  every  manual  of  dentistry  descriptions 
and  illustrations  of  such  irregularities. 


IRREGULARITIES    OF    STRUCTURE.  139 

111  rare  cases,  an  incisor  or  canine  root  is  curved  posteriorly 
like  a  hook,  or  the  radical  extremities  of  upper  and  lower  teeth 
with  multiple  roots  converge  in  the  shape  of  a  bow  which,  some- 
times, forms  a  hook-like  curve  with  a  very  decided  bend  (Atlas, 
Fig,  5).  It  is  not  uncommon  for  the  extremities  of  each  of  the 
roots  of  wisdom  teeth  to  present  a  strong  curve,  or  for  one  of 
them  or  all  of  them  blended  together,  to  be  bent  like  a  hook 
(Atlas,  Fig.  10).  A  quite  uncommon  irregularity  is  that  in 
which  one  root  is  inserted  between  two  others  of  the  same  tooth, 
as  the  thumb  may  be  inserted  between  the  index  and  middle 
fingers  (Atlas,  Fig.  14). 

The  condyloid  enlargements  upon  the  extremities  of  the  roots, 
when  they  are  due  to  irregularities  of  formation,  are  to  be 
ascribed  to  a  hyperplastic  process  which  takes  place  subsequent 
to  the  completion  of  the  root  extremities.  Of  such  a  character 
are  the  larger  or  smaller  pisiform  nodules  Avhich  occupy  the  ex- 
tremities of  the  roots  of  the  lower  molars,  and  offer  serious  ob- 
stacles to  the  extraction  of  these  teeth.  Pisiform,  condyloid 
enlargements  are  also  met  with,  though  very  rarely,  upon  the 
extremities  of  the  radical  portions  of  the  upper  molars. 

Among  the  excessive  formations  in  the  dentine  of  the  root, 
may  be  included  the  concentric  dentinal  formations  (comp.  den- 
tinal new  formations),  when  they  are  located  in  the  root-canal, 
near  the  apex,  in  very  young  teeth. 

c.  Defective  Formation  of  the  Crowns  and  Roots. — Stunted 
crowns  are  indicated  by  a  diminished  superficial  area,  and  by 
the  fact  that  the  incisive  edges,  eminences,  and  cusps  are  less 
marked  than  is  usually  the  case.  The  enamel  layer  frequently  is 
unusually  thin,  or  forms  an  incomplete  investment.  The  enamel 
cap  is  not  everywhere  smooth  upon  its  outer  surface,  the  pol- 
ished appearance  peculiar  to  it  and  its  transparency  are,  in  a 
measure,  lost. 

The  four  upper  incisors,  and,  more  frequently,  the  two  lat- 
erals, sometimes  present,  upon  their  lingual  surfaces,  deep  longi- 
tudinal grooves,  which  commence  upon  the  roots  and  extend  to 
the  ends  of  the  crowns.  Upon  the  same  surfaces  of  these  teeth, 
it  is  not  uncommon  to  find  deep  funnel-shaped  depressions,  or 
pits,  surrounded  by  a  fold-like  elevation  of  the  dental  tissues. 


1-iO  PATHOLOGY. 

To  the  practitioner,  these  grooves  and  pits  have  an  important 
signification,  from  the  fact  that  they  almost  always  are  the  seat 
of  the  commencement  of  caries,  though  the  latter  very  frequently 
continues  unrecognized  until,  finally,  a  hluish  spot  becomes  per- 
ceptible through  the  facial  surface  of  the  incisor.  The  crowns 
of  the  upper  lateral  incisors,  also,  often  possess  narrow,  stunted 
incisive  edges,  in  comparison  with  the  well-developed  ones  of 
the  centrals. 

The  crowns  of  the  wisdom  teeth,  especially  of  the  upper 
ones,  are  most  frequently  stunted  in  their  growth.  When  the 
upper  wisdom  teeth  are  duplicated,  the  normal,  well-developed 
tooth  is  located  in  the  dental  range,  while  the  supernumerary 
one  is  located  without  the  latter,  upon  the  buccal  side,  and  at- 
tains scarcely  two-thirds  the  size  of  the  other. 

A  diminution  in  the  number  of  roots  is  produced  by  a  partial 
or  complete  blending  together  of  the  separate  roots  of  a  molar. 
In  this  manner,  molars  with  two,  and  single  roots  are  formed, 
upon  which,  however,  the  outlines  of  the  roots,  which  should 
have  occurred  normally,  are  more  or  less  distinctly  indicated. 

When  the  three  roots  of  the  upper  first  molars  are  united 
they  acquire  a  pyramidal  form  (Atlas,  Fig.  12).  In  many 
cases,  however,  merely  the  extremities  of  the  two  external 
roots  are  united,  leaving  a  cleft-like  interval,  occupied  by  the 
septum  which  necessarily  must  be  removed  with  the  teeth  when 
they  are  extracted.  When  the  two  external  roots  are  united 
in  their  entire  length,  a  deep  longitudinal  groove  extends 
along  the  external  surface.  Less  frequently  the  extremity  of 
the  internal  rounded  root  is  united  "with  the  two  external  ones. 
When  the  extremities  of  the  three  roots  are  united  together, 
the  latter  form  an  annular  inclosure  around  the  septum  which 
is  inserted  into  the  space  intervening  between  them.  It  is  evi- 
dent, that  such  teeth  cannot  be  extracted  without  fracture  of 
the  septa  between  the  roots  (Atlas,  Fig.  63). 

The  roots  of  the  first  lower  molars,  in  many  cases,  are  united 
throughout  into  single,  wedge-shaped  roots,  the  lines  of  junc- 
tion upon  the  outer  and  inner  surfaces  being  indicated  by 
grooves. 

Coalescence  of  all  the  roots  is  met  with  most  frequently  on 


IRREGULARITIES    OF    STRUCTURE.  141 

tlie  molars,  since  there  is,  usually,  insufficient  space  for  their 
normal  development.  Generally  the  roots  are  grooved  through- 
out, indicating  the  parts  where  union  has  occurred.  "When  the 
roots  are  completely  united,  which  is  more  likely  to  occur  with 
the  upper  wisdom  teeth,  the  single  root  assumes  a  generally 
rounded  appearance  without  any  grooved  markings,  but  the  ex- 
tremities may  diverge  and  be  inserted  in  the  jaw  in  the  form 
of  a  trident,  a  condition  which  renders  the  extraction 
of  such  a  tooth  impossible  without  fracture  of  the  ^^^■^^■'^ 
socket  (Fig.  59). 

In  most  cases  the  coalescence  of  the  roots  of  a  molar 
tooth   is   due  partly  to  an  unusually  short  or  narrow 
maxillary  arch.     The  union  is  formed  by  cement,  which 
partially  or  entirely  prevents  the  development  of  the 
partition  walls  of  the  socket  between  the  roots.     In  certain  in- 
stances, ^Yhere  the  roots  are  separated  by  normal  intervals  and 
are  united  by  osseous  substance,  we  may  assume  the  occurrence 
of  a  hyperplastic  growth  of  cement  from  the  dental  sac. 

Frequently  the  distributio7i  of  the  enamel  over  the  surface  of 
the  coronal  dentine  is  not  uniform  ;  here  and  there,  it  is  de- 
fective, Avhile  the  denthie,  corresponding  with  the  very  distinct 
depressions  and  grooves  upon  the  crowns,  either  is  entirely  un- 
protected or  covered  merely  by  a  thin  layer  of  enamel;  on  the 
other  hand,  the  enamel  is  disproportionately  thick  in  some  lo- 
calities ;  for  example,  upon  the  dental  cusps  and  eminences 
where  the  enamel  occurs  in  the  form  of  pediculated  nodules. 
These  appearances  are  presented  generally  by  the  greater  num- 
ber of  the  teeth  in  a  set  and,  not  uncommonly,  are  hereditary. 

The  permanent  teeth  are  more  frequently,  and  the  milk  teeth 
more  rarely,  the  subjects  of  these  conditions;  they  are  most 
conspicuous  upon  the  incisors,  canines,  and  upper  first  molars, 
and  are  met  with  less  frequently  upon  the  lower  first  molars 


*  Fig.  59  shows  a  stunted  upper  wisdom  tooth  from  the  right  side.  The 
masticating  surface  of  the  crown  presents  four  blunt  cusps.  The  roots  are 
united  into  one  cylindrical  root,  the  extremity  of  which  expands  into  three 
short  prongs,  so  tlMt  the  tooth  could  not  be  separated  entirely  without  break- 
ing away  a  portion  of  the  alveolar  process.  Natural  size.  (For  the  use  of 
this  specimen  the  author  is  indebted  to  Dr.  Friedlowski.) 


142  '  PATHOLOGY. 

and  bicuspids.  The  appearances  presented  by  the  malformed 
enamel  in  these  cases  are  very  characteristic.  The  surface  of 
the  enamel  otherwise  smooth,  frequently  is  studded  like  a 
thimble,  with  numerous  minute  pits,  some  of  which  extend  as  far 
as  the  dentine ;  sometimes  it  is  traversed  by  transverse  grooves 
which  are  bounded  by  ridges.  In  such  instances,  however,  it  is 
to  be  borne  in  mind  that,  although  the  external  enamel  layers 
present  numerous  pits,  the  internal  layers 
Fir.,  co.'^  towards  the  dentine  are  invariably  found  to 

be  smooth  (Fig.  60).  The  thickened  deposits 
of  enamel  occur  upon  the  crenated  incisive 
edges  of  the  incisors  where  fenestrated  open- 
ings are  met  with  which  dip  down  as  far  as 
the  dentine.  Such  teeth  present  a  trans- 
versely grooved  appearance. 
The  cribriform,  foraminated  enamel  upon  the  crowns  of  teeth 
with  multiple  roots  is  commonly  limited  to  the  masticating  sur- 
faces, where,  also,  are  located  the  papilliform  thickened  deposits 
of  enamel.  I^ot  infrequently  half  the  crown  is  destitute  of 
enamel,  only  the  portion  adjacent  to  the  neck  of  the  tooth  being 
covered. 

These  defects  in  the  formation  of  the  enamel  are  generally 
included  under  the  head  of  Atrophy  in  the  manuals  of  dentistry, 
but  this  latter  term  is  incorrectly  applied,  since  defective  forma- 
tion and  atrophy  are  not  identical. f 

*  Fig.  60. — View  of  the  interior  of  the  enamel  cap  of  a  fully  formed 
molar,  from  the  jaw  of  a  young  person  ;  its  outer  surface  was  studded  with 
numerous  depressions  ;  the  cap  was  isolated  by  means  of  a  fifty  per  cent, 
solution  of  sulphuric  acid.  The  central  portion  of  the  grinding  surface  pre- 
sents a  bifurcating  fissure,  to  the  right  of  which  is  a  cavity  the  result  of  a 
suspension  of  the  process  of  enamel  formation  at  this  point.  Witliin  the 
parietal  wall  is  a  groove  (a),  having  the  character  of  a  sort  of  suture,  where, 
likewise,  the  development  of  the  enamel  was  interrupted  for  a  certain  period. 
Magnified  two  diameters. 

f  These  malformations  are  considered,  without  reason,  by  many  practi- 
tioners, to  be  caused  by  hot  drinks,  sweet  and  sour  articles  of  food,  the  use 
of  acid  preparations  for  the  teeth,  or  other  medicaments.  They  are  referred, 
also,  to  a  scrofulous  diathesis  by  some  who,  however,  adduce  no  plausible 
reasons  for  such  an  opinion.  The  truth  is,  that  the  only  explanation  which 
can  be  relied  upon  is  to  be  attained  upon  anatomical  grounds,  and  this  way 


IRREGULARITIES    OF    STRUCTURE.  143 

It  is  the  general  opinion  that  teeth  of  this  kind,  with  so  many 
depressions  upon  their  coronal  surfaces  giving  to  them  a  disa- 
greeable appearance,  are  very  liable  to  be  affected  with  caries  at 
an  early  period,  but  they  may,  however,  be  preserved  with 
proper  care  and  cleanliness. 

•Recently-cut  molars  are  met  with  occasionally  in  which, 
whether  they  are  the  subjects  of  the  enamel  defects  just  de- 
scribed or  not,  the  continuity  of  the  enamel  at  the  bottom  of 
the  grooves  is  interrupted,  so  that  a  fine  probe  may  be  inserted 
into  the  fissures  which  remain,  as  far  as  the  dentine.  In  these 
cases,  evidently,  the  development  of  the  enamel  has  been  defec- 
tive, since  the  enamel  caps,  which  should  cover  the  prominences 
of  the  teeth  and  form  continuous  layers  in  the  grooves  between 
them,  present  interruptions  in  their  continuity. 

Defectively  developed  enamel  is  characterized  histologically 
by  the  granular  cloudiness  of  separate  portions  in  which  the 
structure  is  more  or  less  altered  and  irregularly  jagged  borders 
are  directed  towards  the  normally  developed  enamel.  With 
this  condition,  the  enamel  is  capable  of  less  resistance  and  easily 
crumbles.  Very  frequently,  abundant  deposits  of  dark-brown  or 
blackish-brown  pigment  are  observed,  which  render  the  structure 
of  the  enamel  quite  unrecognizable  in  places. 


was  Huggested  long  ago  by  Bourdet  (De  I'art  du  Deiitiste,  1757,  p.  79),  who 
treated  of  such  deformities  under  the  name  of  Erosion,  and  considered  them 
to  be  due  to  rachitis,  scorbutus,  lo<v  forms  of  fever,  measles,  variola,  and,  in 
general,  to  all  those  diseases  in  which  the  quality  of  the  fluids  is  at  fault. 
If,  he  says,  the  appearance  of  the  disease  is  coincident  with  the  commence- 
ment of  ossification  in  the  formation  of  the  tooth,  that  portion  which  has 
not  yet  attained  its  proper  consistence  becomes  principally  affected  and  de- 
ficient in  enamel  ;  as  soon  as  the  disease  comes  to  an  end  and  the  fluids  ac- 
quire a  favorable  condition,  then  the  development  of  the  remainder  of  the 
tooth  is  resumed  in  a  regular  manner,  so  that  the  enamel  is  white  and  smooth 
in  the  vicinity  of  the  root,  and  abnormally  formed  towards  the  extremity  of 
the  coronal  portion.  The  surgeon.  Tenon,  exhibited  to  Bourdet  a  series  of 
jaws,  by  which  it  could  be  demonstrated  that  the  erosion  took  place  while 
the  tooth  was  still  within  its  capsule,  and  that  the  tooth,  when  it  was  ready 
for  eruption,  was  less  liable  to  erosion;  those  teeth,  whose  formation  was 
most  advanced,  exhibited  the  least  traces  of  the  erosion  towards  the  upper 
coronal  surface,  and  the  most  notable  evidences  towards  the  neck  of  the 
tooth ;  finally,  those  teeth  whose  crowns  had  emerged  nearly  to  a  level  with 
the  alveolar  margins,  and  whose  roots  were  still  short,  were  barely  aflected. 


144 


PATHOLOGY. 


Fig.  61* 


The  depressions  in  the  enamel  present,  externally,  a  wide 
opening,  or,  less  frequently,  are  con- 
stricted, so  as  to  form  a  sort  of  neck. 
The  entire  internal  surface  of  the  de- 
pression is  covered  with  enamel,  which 
may  be  of  a  normal  character,  with  the 
exception  of  a  variation  in  the  arrange- 
ment of  the  prisms  (Fig.  61). 

"Where  portions  of  the  enamel,  es- 
pecially its  peripheral  layers,  are  ex- 
tremely cloudy  in  appearance,  its  im- 
perfect formation  has  resulted  in  a 
granular  calcareous  mass  (Fig.  62). 
The  furrows  upon  transversely- 
grooved  crowns  give  a  terraced  appearance  to  the  enamel,  when 
seen  in  profile,  though  upon  the  surface  towards  the  dentine  the 
enamel  is  smooth,  and,  therefore,  the  portions  corresponding  to 
the  depressions  are  thinner  than  others  (Atlas,  Fig.  16). 

The  laminae  of  grooved  enamel  conform,  in  their  disposition, 

to  the  terrace-like  outline  of  the 
exterior,  that  is  to  say,  they  ex- 
tend, from  one  terrace  (Absatz) 
to  another,  in  a  series  of  planes 
parallel  to  the  outer  surface ; 
when  viewed  in  a  longitudinal  sec- 
tion of  the  crown,  they  describe  a 
\_    __^,    ^    .■ — """^^1^'  system  of  concentric  arches,  and 

beneath  each  transverse  depres- 
sion, the  system  of  laminae,  which  is  more  remote  from  the  incisive 


Fig.  62.t 


#' 


*  Fig.  61  shows  a  spherical  excavation  in  the  enamel.  A  funnel-shaped 
depression  dips  down  from  the  surface  to  a  considerable  depth  into  the 
enamel,  where  it  is  connected  with  the  spherical  cavity  by  means  of  a  sort  of 
neck.  The  wall,  which  appears  intact  in  the  transverse  section,  is  covered 
with  normally-formed  enamel  prisms  which,  for  the  most  part,  are  divided 
transversely  and  obliquely.     Magnified  250  diameters. 

f  Fig.  62. — Imperfectly-developed  enamel  with  extreme  granular  cloudi- 
ness and  numerous  pits  in  its  peripheral  portions.  In  the  brownish-clouded 
mass  of  the  deeper  layers,  enamel  prisms,  divided  transversely  and  obliquely, 
(a)  may  still  be  recognized.     Towards  the  masticating  surface,  however,  the 


IRREGULARITIES    OF    STRUCTURE.  145 

edge  or  coronal  apex,  and  is  situated  posteriorly  in  the  horizontal 
plane,  joins  the  adjacent  system  in  front  of  it.  The  depressed 
portions  commonly  are  the  seat  of  extensive  deposits  of  pigment. 

The  continuity  of  the  dentinal  tissue  of  grooved  teeth  is  always 
interrupted,  here  and  there,  by  the  interposition  of  large  globular 
masses.  The  latter  extend  from  the  white  zones,  which  are 
perceptible  upon  the  exterior  of  the  roots,  in  an  oblique  direc- 
tion towards  the  croAvn,  where  they  are  crowded  together.  The 
substance  of  the  globular  masses  is  transparent,  while,  on  the 
contrary,  the  interglobular  masses  frequently  have  a  brownish- 
yellow  color,  varying  from  this  to  a  dark  brown.  The  internal 
surface  of  the  dentine  not  infrequently  presents  disordered  sys- 
tems of  dentinal  canals  and,  in  the  vicinity  of  the  extremity  of 
the  root,  concentric  dentinal  formations. 

The  cement  of  grooved  teeth,  likewise,  presents  some  anomalies 
of  development.  The  exterior  is  not  everywhere  even,  and  in 
some  localities  is  so  thin  that  the  globular  masses  which  are  dis- 
posed in  the  superficial  dentinal  layer  are  visible  through  it,  at 
certain  intervals,  in  the  form  of  the  white  zones  mentioned  above. 
Towards  the  apex  of  the  root  flattened,  tuberculated  elevations 
of  the  cement  are  frequently  met  wnth.  In  the  latter  locality, 
also,  irregular  cavities  are  often  found,  which  extend  into  the 
dentine. 

Teeth  of  such  a  character  as  have  been  described  are  due  to 
disturbing  causes  which  occur  at  intervals  during  the  process  of 
their  formation,  and  prevent  their  uninterrupted  development. 
In  proof  of  the  periodical  occurrence  of  a  disturbing  cause  may  be 
cited  the  following :  «,  in  reference  to  the  enamel,  that  its  lamina 
do  not  fall  away  uniformly  from  the  incisive  edge  or  coronal  apex 
towards  the  neck  and  diminish  in  number,  but  breaks  (Absatze) 
are  formed,  each  of  which  includes  a  system  of  layers ;  h,  the 
fact,  that  imperfectly-developed  dentine,  in  the  form  of  globular 
masses,  is  intercalated,  and  conforms  in  its  disposition  to  that 

latter  do  not  preserve  their  arrangement  in  rows,  but  lie  scattered  in  a 
granular  basis-substance,  are  grouped  together  here  and  there  (6),  present  a 
shrivelled  appearance,  are  indicated  by  a  dark-bordered  outline  and,  now 
and  then,  are  transformed  into  a  brownish-black  mass  of  pigment.  Magnified 
400  diameters. 

10 


14G  PATHOLOGY. 

of  the  layers  forming  the  coronal  and  radical  portions ;  hence 
may  be  inferred  the  occurrence  of  an  interruption  to  the  com- 
plete formation  of  the  dentine  ;  moreover,  the  irregular  disposi- 
tion of  the  layers  upon  the  internal  surface  of  the  dentine  favors 
the  view  of  an  interruption  to  its  symmetrical  development ;  c, 
in  regard  to  the  cement,  the  fact  that  its  development  progresses 
merely  to  the  formation  of  a  thin  layer,  and  that  the  evidences 
of  resorption  in  the  cement  as  well  as  in  the  dentine  occur  at 
the  radical  extremity;  consequently,  the  growth  of  the  extremity 
of  the  root  was  not  uniform.  Another  circumstance  in  favor  of 
the  above  view  is,  that  these  anomalies  of  formation  are  never 
found  except  in  teeth  whose  development  takes  place  at  about 
the  same  period  and,  also,  under  nearly  similar  conditions,  while 
teeth  formed  at  a  later  period  commonly  are  quite  free  from 
these  irregularities.* 


*  Hutchinson  asserts  that  certain  deviations  in  the  forms  of  teeth  are 
valuable  as  diagnostic  marks  of  the  existence  of  congenital  constitutional 
syphilis,  and  he  classes  them  with  syphilitic  interstitial  keratitis.  Albrecht 
(Deutsche  Yiertelj.  f.  Zahnheilk.,  1862),  in  an  extended  criticism  of  these 
statements,  observes  that  he  cannot  conceive,  in  the  first  place,  why  the 
permanent  canines  and  incisors  only  are  affected,  and  why  the  milk  teeth 
were  not  also  included  by  Hutchinson  in  his  observations.  From  the  de- 
scriptions given  of  the  deviations  in  form,  that,  namely,  the  upper  central 
incisors,  after  their  eruption,  are  generally  short,  compressed  laterally  in 
the  direction  of  the  cutting  edges,  and  are  very  thin ;  that,  after  some  time, 
a  crescent-shaped  piece  becomes  detached  from  the  cutting  edges,  leaving  a 
shallow  groove ;  that  the  two  teeth  frequently  converge  towards  one  another, 
and  at  times  are  wide  apart;  that  they  have  a  peculiar  color,  and  a  narrow 
quadrangular  shape:  all  these  are  insufficient  to  afford  positive  grounds;  the 
pre-existence  of  syphilis,  moreover,  is  not  proved  in  many  cases.  Adequate 
proofs  therefore  are  still  wanting  of  the  occurrence  of  an  hereditary  syphilitic 
deformity  of  the  teeth. 

[This  is  contrary  to  the  opinion  of  many  prominent  medical  men  in  this 
country  and  Europe. 

Mr.  Jonathan  Hutchinson,  in  summing  up  a  large  number  of  cases  of  in- 
terstitial keratitis  in  reference  to  the  deformity  of  the  teeth,  says  (Ophthal- 
mic Hospital  Keports,  1859,  vol.  ii,  page  96) :  "  In  those  who  bad  cut  their 
permanent  set,  the  condition  of  the  incisor  teeth  was  very  peculiar,  both  in 
form,  color,  and  size.  As  diagnostic  of  hereditary  syphilis,  various  pecu- 
liarities are  often  presented  by  the  others,  especially  the  canines;  but  the 
upper  central  incisors  are  the  test  teeth.  When  first  cut,  these  teeth  are 
short,  narrow  from  side  to  side  at  their  edges,  and  very  thin.    After  awhile, 


IRREGULARITIES    OF    STRUCTURE.  147 

d.   Blending   or  Fusion,  and    Coalition  or   Concrescence  of 
Adjacent     Teeth. — Fusion    (Yerschmolzung)    of    two   adjacent 

a  crescentic  portion  from  their  edge  breaks  away,  leaving  a  broad,  shallow, 
vertical  notch,  which  is  permanent  for  some  years,  but  between  twenty  and 
thirty  usually  becomes  obliterated  by  the  premature  wearing  down  of  the 
tooth.  The  two  teeth  often  converge,  and  sometimes  they  stand  widely 
apart.  In  certain  instances  in  which  the  notching' is  either  wholly  absent 
or  but  slightlj'  marked,  there  is  still  a  peculiar  color,  and  a  narrow  square- 
ness of  form,  which  are  easily  recognized  by  the  practiced  eye Since 

I  have  made  it  a  rule  always  to  look  into  the  mouth,  however,  I  have  not 
met  with  a  single  example  of  well-characterized  interstitial  keratitis  in 
which  the  teeth  were  of  normal  size  and  shape.  Indeed  there  can  be  no 
doubt  whatever  as  to  the  truth  of  the  assertion  that  malformed  upper  incisors 
(permanent  set)  are  all  but  invariably  coincident  with  this  disease.  A  few 
months'  observation  at  any  large  ophthalmic  institution  will  satisfy  any  one 
of  this  clinical  fact." 

Dr.  B.  W.  Kichardson,  in  "  The  Medical  History  and  Treatment  of  Dis- 
eases of  the  Teeth  and  the  Adjacent  Structures,"  London,  1860,  page  15, 
says :  "In  reference  to  the  effects  of  the  syphilitic  poison  on  the  development 
of  both  the  temporary  and  permanent  teeth,  the  influence  is  undeniable,  and 
I  think  it  possible  that  there  is  scarcely  any  chronic  disorder  of  the  dental 
structure  which  is  not  influenced  more  or  less  by  the  effects  of  the  syphilitic 
diathesis  when  present.  But  there  seems  also  to  be  a  special  afi'^tion  of  the 
teeth  due  to  the  hereditary  syphilitic  disease."  He  then  refers  to  Mr. 
Hutchinson's  investigations  as  supporting  his  statement. 

Dr.  Langdon  Down,  in  a  paper  read  before  the  "  Odontological  Society  of 
Great  Britain,"  "On  the  Eelation  of  the  Teeth  and  Mouth  to  Mental  De- 
velopment" (Transactions,  1871,  vol.  4),  in  speaking  of  this  peculiar  de- 
formity as  occurring  in  the  feeble-minded  who  have  come  under  his  observa- 
tion, says  (page  17) :  "  Very  few  have  had  syphilitic  teeth ;  but  when  I  did 
discover  them,  I  always  had  confirmatory  evidence  of  the  syphilitic  history 
of  the  case,  and  the  condition  of  the  teeth  was  always  associated  with  the 
chronic  inflammation  of  the  cornea  to  which  Mr.  Hutchinson  has  called 
attention." 

Dr.  E.  Magitot  (in  "  Traite  de  la  Carie  Dentaire,"  1867,  page  67)  says: 
"Syphilis,  especially,  produces  disastrous  effects  upon  the  teeth',  and  we  see 
that  children  aft'ected  with  hereditary  syphilis  present  small  teeth,  deformed, 
showing  deep  channellings  ;  and  the  enamel  and  dentine,  imperfectly  calci- 
fied, are  covered  with  opaque  spots,  and  remain  permanently  weak  and 
friable." 

Henry  W.  Williams,  M.D.,  Professor  of  Ophthalmology  in  Harvard  Uni- 
versity, a  very  eminent  authority  in  this  country,  in  "  Kecent  Advances  in 
Ophthalmic  Science,"  1871,  also  confirms  Mr.  Hutchinson's  observations. 
He  says  (page  56) :  "  The  central  incisors  of  the  second  dentition  have  a 
peculiar  crescentic  notch  at  their  lower  margins,  and  the  lateral  incisors  and 
canines,  as  well  as  the  molars,  are  often  small,  peg-shaped,  and  with  tuber- 


148 


PATHOLOGY. 


teeth  signifies  an  organic  union  between  them,  which  takes  place 
(Turin ff  their   development.     Coalition  (Verwachsung)   denotes 


culated  prominences  upon  their  surface.     They  are  perhaps  also  irregularly 
set  in  the  jaw,  and  of  bad  color,  or  prematurely  decayed." 

These  conditions  have  for  some  years  been  recognized  by  many  dental 
practitioners.  They  must  not  be  confounded  with  those  which  occur  as  the 
result  of  interrupted  development,  illustrated  by  the  longitudinal  grooving, 
with  depressions  or  pits,  in  the  enamel,  caused  by  a  perversion  of  nutrition 
induced  by  some  of  the  non-specific  infantile  diseases. 

The  appearance  of  syphilitic  teeth  is  well  shown  by  the  accompanying 
plates,  which  were  kindly  furnished  through  the  courtesy  of  Dr.  Williams. 
"  Figures  A  and  B  show  the  condition  of  the  teeth  in  a  boy  and  girl  aged 
about  twelve  and  fourteen.  In  Figure  C,  from  a  girl  of  seventeen,  the 
notched  appearance  has  already  become  lessened  by  wear  of  the  teeth." 

T.  B.  H. 


Fig.  A. 


Fig.  C. 


Albrecht  considers  it  strange  that  only  the  permanent  incisors  and  canines 
are  affected,  but  Dr.  Williams  has  shown  that  the  molars  also  are  subject  to 
a  peculiar  deformity.  A  close  examination  of  Mr.  Hutchinson's  paper  shows, 
that  in  a  number  of  cases  he  does  include  the  temporary  teeth,  giving  several 
instances  of  their  early  destruction  or  loss.  This  is  also  verified  by  the  ob- 
servations of  Dr.  Williams,  as  well  as  by  a  cast  in  the  Museum  of  the  Dental 
Department  of  Harvard  University. 

The  reason  that  this  condition  of  the  temporary  teeth  has  not  been  recog- 
nized more  often  is,  probably,  because  the  subjects  of  interstitial  keratitis 
generally  do  not  come  under  the  observation  of  the  oculist  until  from  ten 
to  eighteen  years  of  age,  when  most  of  the  temporary  teeth  are  lost,  and 
their  places  have  been  supplied  by  those"  of  the  permanent  set. — T.  B.  H.] 

Hohl  (Deutsche  Viertelj.  f.  Z.,  1869)  found  a  very  abundant  secretion  of 
an  acid  saliva  in  a  child,  seven  years  of  age,  affected  with  congenital  hydro- 
cephalus. All  the  teeth  were  of  a  grayish-yellow  color,  and  smaller  than 
milk  teeth ;  the  enamel  was  wanting  almost  entirely,  without  any  evidences 
of  caries.  In  the  cement  and  dentine  there  were  to  be  seen  numerous  canals, 
and  also  gaps  resulting  from  resorption,  and  in  the  latter  was  an  evident 
disposition  to  laminated  arrangement,  with  numerous  interglobular  spaces. 
Hohl  considers  that,  in  this  case,  there  was  an  arrest  of  the  development  of 
the  teeth,  and  a  decalcification  of  the  same  upon  their  outer  surfaces.  Owing 
to  the  absence  of  Leptothrix  buccalis,  he  says,  caries  could  not  have  occurred. 


IRREGULARITIES    OF    STRUCTURE.  149 

an  organic  union  by  means  of  cement,  which  ensues  aftei'  the 
completion  of  their  development.  The  former  arises  from  the 
coalescence  of  two  adjacent  germs,  and  must  not  be  confounded 
with  a  twin-malformation,  by  which  is  understood  a  malforma- 
tion by  duplication  instead  of  a  unification  of  normally  exist- 
ing parts.  In  fusion,  the  tissues  of  the  teeth  which  in  other 
cases  are  separated  by  an  interval  pass  from  one  to  another 
without  interruption,  and  the  line  of  demarcation  between  the 
teeth  is  indicated  by  a  more  or  less  deep  groove,  similar  to  a 
raphe. 

Fusion  is  of  two  kinds,  complete,  when  both  the  coronal  and 
radical  portions  are  united,  and  partial,  when  the  union  is 
limited  to  the  crowns  or  the  roots.  The  teeth  may  be  united  in 
their  normal  positions  or  at  angles  with  each  other,  so  that  one 
tooth  may  preserve  its  normal  position,  while  the  other  is  twisted 
180°,  with  its  lingual  surface  facing  outwards. 

Blended  crowns  contain  common  pulp-cavities,  blended  roots, 
common  or  divided  canals.  Adhesions  of  adjacent  teeth  are 
confined  to  the  roots,  each  of  which  contains  a  separate  canal. 

Fusions  belong  to  the  category  of  rare  occurrences,  and 
affect  both  the  milk  and  permanent  teeth.  They  are  particu- 
larly liable  to  be  overlooked  in  the  milk  teeth,  because,  corres- 
ponding with  the  line  of  junction  of  the  borders,  there  is  a  deep 
groove  generally,  which  is  likely  to  be  mistaken  for  a  complete 
division  between  the  two  teeth.  Heider  mentions  nineteen  ex- 
amples of  blended  teeth,  in  his  collection,  eight  of  which  belong 
to  the  milk,  and  eleven  to  the  permanent  teeth.  The  latter  in- 
clude three  cases  of  fusion  of  the  upper  left  central  with  the 
lateral  incisor,  and  one  of  the  lower  right  central  with  the  lat- 
eral incisor  ;  two  cases,  upon  the  right  and  left  sides  respectively, 
in  which  the  upper  second  molar  is  blended  with  the  wisdom 
tooth,  and  one  instance  similar  to  the  latter,  where  the  lower 
second  molar  and  wisdom  tooth  are  united ;  in  one  case,  a  lower 
right  wisdom  tooth  is  blended  with  a  supernumerary  wisdom 
tooth ;  and  finally,  one  presents  a  fusion  between  a  lower  Avisdom 
and  a  so-called  conical  supernumerary  tooth.  (Two  cases  are 
not  specified.) 

The  blended  milk  teeth  are  limited  chiefly  to  those  of  the 


150  PATHOLOGY. 

upper  jaw ;  in  three  of  the  cases,  the  central  is  united  Avitli  the 
lateral  incisor;  in  four  of  them,  the  laterals  are  blended  with 
canines,  and,  finally,  in  one  case  a  lower  milk  canine  is  united 
with  the  first  milk  molar. 

A  more  precise  anatomical  examination  of  blended  teeth  with 
single  roots,  verifies  the  opinion  which  might  be  inferred  before- 
hand, merely  from   a   superficial  inspection  :   a  common  pulp- 
cavity  prolonged  into  each  of  the  two  crowns  and  a 

Fig  r,:i*  "^ 

root-canal  common  to  the  two  in  some  cases  and,  in 
others,  divided  (Fig.  63).  Under  the  microscope, 
cross-sections  show  an  immediate  transition  of  the 
dentine  of  one  tooth  into  that  of  the  other,  a  more 
circuitous  course  of  the  dentinal  canals,  as  if  they 
were  bent,  being  perceptible  only  at  the  points  cor- 
responding with  the  external  groove.  The  enamel 
surrounds  the  coronal  portion  of  the  dentine  in  a  very  uniform 
manner  and  dips  down  to  the  bottom  of  the  grooves,  in  order 
to  cover  them  throughout  in  the  same  way  as  upon  multicuspid 
teeth  (Atlas,  Fig.  22).  Hence  it  follows  that  it  is  impracticable 
to  think  of  separating  blended  teeth  at  the  groove  by  means  of 
a  file,  since  by  such  a  procedure,  the  pulp-cavity  would  evi- 
dently be  opened,  the  pulp  injured,  and  the  existence  of  both 
teeth  jeopardized. 

A  complete  fusion  is  not  conceivable  except  it  occurs  in  a 
dental  sac,  common  to  the  two  teeth,  and  since  we  know  from 
the  history  of  its  development,  that  the  formation  of  the  dental 
sac  belongs  to  an  early  period,  therefore  the  fusion  must  neces- 
sarily be  of  early  origin.  We  are  able,  however,  to  go  still 
farther  and  say,  that  the  fusion  ensues  contemporaneously  with 
the  first  development  of  the  enamel  organ  and  dentinal  germ, 
since  we  find  that  the  dentine  of  one  passes  directly,  without 
interruption,  into  that  of  the  other  tooth,  and  a  continuous 
enamel  cap  covers  the  united  coronal  portions  of  the  dentine. 
As  the  cement  of  a  single  root  is  formed  from  a  single  sacciform 

*  Fig.  63. — Perpendicular  section  through  two  teeth  (the  central  and  lat- 
eral milk  incisors)  which  were  blended  together.  View  of  the  posterior 
half,  showing  the  communication  between  the  two  pulp-cavities  and  the 
union  of  the  two  root-canals  at  the  extremity  of  the  root.     Natural  size. 


IRREGULARITIES    OF    STRUCTURE.  151 

elongation  of  the  dental  sac,  and  a  double  root  presupposes  a 
double  elongation  of  the  dental  sac,  we  may  explain  the  occur- 
rence of  the  separation  of  the  respective  roots  of  crowns,  Avhich 
themselves  are  blended  together,  bj  the  supposition  of  a  division 
of  the  dentinal  germ  which  forms  the  root.  The  raphe  corres- 
ponds to  the  line  of  junction  and  fusion  of  the  two  germs. 

The  possibility,  that  two  separate  crowns  might  be  blended 
together  by  a  resorption  of  the  proximal  surfaces,  or  that  two 
perfectly  formed  and  separate  roots,  each  with  its  canal,  might 
be  united  into  one  root  with  a  common  canal,  is  quite  incon- 
ceivable. 

The  fusion  of  the  roots  of  adjacent  teeth  implies  a  union  of 
the  root-pulp  of  one  tooth  with  that  of  the  adjacent  one,  in 
such  a  manner  that  ultimately  by  the  junction  of  the  root-canals 
of  both  teeth,  usually  at  an  acute  angle,  a  single  canal  is  pro- 
duced, terminating  in  the  single  root  extremity.  Such  a  union 
cannot  take  place  except  during  the  development  of  the  roots 
of  adjacent  teeth,  and  it  is  impossible  for  it  to  be  induced  by  a 
pathological  process  occurring  after  the  complete  formation  of 
the  roots  of  the  two  teeth. 

An  example  may  serve  to  explain  the  preceding  observations. 
A  right  upper  jaw  presents  a  fusion  of  the  posterior  external 
root  of  the  first  molar  with  the  anterior  external  root  of  the 
second  molar.  The  cavity  of  an  abscess  surrounds  the  two 
roots  mentioned  and  the  anterior  external  root  of  the  first 
molar.  The  extremities  of  the  roots  involved  lie  exposed,  while 
the  facial  wall  of  the  jaw  and  the  alveoli  have  been  destroyed  by 
suppuration.  The  crown  and  internal  root  of  the  first  molar 
have  been  destroyed  by  caries.  The  proximal  surfaces  of  the 
two  first-named  roots  are  completely  united  in  their  upper 
halves.  Both  teeth  are  movable  together.  The  fusion  of  the 
two  roots  has  occurred  in  such  a  manner  that  there  is  one  root- 
canal  common  to  both  which  corresponds  more  nearly  to  the  di- 
rection of  the  anterior  root  of  the  second  molar.  The  dentinal 
canals  radiate  from  this  canal  in  such  a  manner  that  there  is  no 
separation  between  the  dentine  of  the  two  roots ;  the  canal 
mentioned  forms  therefore  the  common  centre  of  the  two  roots. 
The  cement  forms  an  uninterrupted  investment  to  the  latter, 


152 


PATHOLOGY. 


except  at  a  point  upon  the  posterior  root  of  the  first  molar, 

where  can  be  seen  "with  the 
Fig.  fi4.*  naked  eye  a  fissured  defect 

in  the  substance.  Upon 
cross-section  the  fissure  may 
be  traced  in  the  form  of  a 
raphe,  into  the  common  cen- 
tral canal  (Fig.  64). 

As  the  blending  of  the 
roots  in  the  way  described 
cannot  be  the  result  of  an 
abscess  of  the  root-mem- 
brane, it  must  rather  be  ad- 
mitted, although,  as  is  well  known,  an  interval  of  about  six 
years  occurs  between  the  eruption  of  the  crowns  of  the  first  and 
second  molars,  that,  nevertheless,  a  fusion  of  these  roots  and  the 
formation  of  a  common  root-canal  took  place  during  the  process 
of  their  development. 

An  anatomical  examination  alone  can  determine  whether  a 
case  in  hand  is  one  of  fusion.  Therefore  it  admits  of  doubt 
whether  the  cases  cited  as  fusions  (Atlas,  Fig.  18  and  21)  are 
really  such,  in  the  strictly  correct  sense  of  the  word. 

Coalition  or  concrescence  of  the  roots  of  adjacent  teeth  takes 
place  subsequent  to  the  complete  formation  of  the  roots  and, 
evidently,  cannot  occur  without  the  previous  resorption  of  the 
alveolar  segments  between  the  two  roots  which  are  united.  In 
these  cases,  the  question  at  once  arises,  why  the  cement  layer 
of  the  root  does  not  become  adherent  to  the  alveolus  ?  I  have 
frequently  sought  for  such  adhesions,  but  have  never  observed 
anything  but  mere  contact  with  a  very  small  portion  of  the  al- 
veolus ;  remove  this  fragment,  which  may  easily  be  done,  and 
the  root  lying  beneath  it,  presents  a  very  smooth  appearance, 
nor  does  a  cross-section  of  the  part  in  question  indicate  any  ad- 
hesion. The  explanation  of  this  fact  is  to  be  sought  for  in  the 
periosteum  of  the  root,  which,  as  before  observed,  is  a  product 


*  Fio.  64  shows  a  fusion  of  the  posterior  external  root  of  the  upper  first 
molar  with  the  anterior  external  root  of  the  second  molar.  ^lagnified  ton 
diameters. 


IRREGULARITIES    OF    STRUCTURE.  153 

of  the  submucous  layer  of  the  gum.  The  capillary,  vascular 
system  of  the  root-membrane  lies  upon  the  surface  towards  the 
cement ;  in  that  direction,  therefore,  the  plastic  elements  for  the 
new  osseous  layers  are  excreted,  and  it  is  impossible  for  them  to 
be  deposited  in  the  opposite  direction. 

When  now  resorption  of  the  contiguous  alveoli  and  the  os- 
seous septa  between  the  roots  has  occurred,  which  probably  is 
promoted  by  the  vessels  of  the  septum,  the  periosteum  of  the 
two  roots  comes  into  contact  and,  from  the  continued  deposition 
of  new  layers  of  cement,  there  results,  finally,  a  coalition  of  the 
two  roots. 

These  adhesions  of  the  roots  of  adjacent  teeth  are  found,  in 
most  cases,  towards  the  extremities,  but  they  also  occur  in  the 
middle  portions.  If  the  union  takes  place  before  one  or  the 
other  tooth  has  advanced  to  its  proper  level  in  the  dental  range, 
then  will  its  complete  eruption  be  prevented  (compare  Reten- 
tion). This  form  of  union  seems  to  occur  most  frequently  be- 
tween the  upper  second  molars  and  wisdom  teeth.  The  probable 
reason  for  this  may  be  found  in  the  fact  that  the  roots  of  the 
upper  molars,  in  consequence  of  their  great  divergence,  are  very 
liable  to  come  into  close  relation  with  one  or  another  root  of  the 
adjacent  teeth,  and,  further,  that  the  eruption  of  the  wisdom 
teeth  occurs  comparatively  slowly  and,  not  infrequently,  is  at- 
tended with  important  obstructions,  among  which  may  be  men- 
tioned an  hypertrophy  of  the  cement.  Probably 
an  irritation,  applied  to  a  larger  or  smaller  por-  fig.  05.* 

tion  of  the  root-membrane,  is  the  predisposing 
cause,  the  result  of  which,  a  notable  thickening 
of  the  cement,  is  illustrated  in  Figs,  48  and  49. 

In  rare  cases,  the  roots  of  the  front  teeth  may 
be  united  in  their  middle  portions  in  consequence 
of  their  very  marked  convergence  (Fig.  65).  '*~-ij'/ 

*  Fig.  65  shows  an  organic  adhesion,  about  five  millimetres  in  extent,  be- 
tween a  permanent  upper  left  central  and  the  lateral  incisor,  at  the  middle 
portion  of  the  contiguous  surfaces  of  the  roots.  The  two  crowns,  necks 
and  radical  extremities  are  entirely  separated.  The  central  incisor  is  in- 
clined laterally.  The  descent  of  the  lateral  to  the  level  of  the  dental  range 
was  prevented  in  consequence  of  the  adhesion      Natural  size. 


154  PATHOLOGY. 

Many  persons  suppose  they  have  seen  cases  in  which  all  the 
teeth,  even  upon  the  crowns,  were  adherent  to  one  another,  but 
such  an  occurrence  is  not  conceivable,  when  it  is  considered  that 
the  teeth  make  their  appearance  singly,  at  different  periods,  and 
after  intervals  of  years  in  some  cases.  Sdmmering  and  Blumen- 
thal,  indeed,  have  shoAvn  that  these  supposed  organic  adhesions 
are  produced  by  the  tartar  of  the  teeth  which  cements  them 
together ;  nevertheless  this  fable  of  travellers  still  has  its  be- 
lievers. 

These  organic  unions  by  fusion  and  by  coalition,  which  have 
been  mentioned,  are  of  interest  to  the  practitioner  from  the  fact 
that,  without  making  proper  examination,  he  may  commit  the 
error  of  extracting  not  only  the  tooth  he  desires  to  remove,  but 
also  its  neighbor  at  the  same  time.  Of  course,  the  latter  evil 
cannot  be  avoided,  when  the  extraction  of  the  tooth  at  fault 
has  become  an  imperative  necessity.  Still  it  is  always  an  un- 
pleasant occurrence  for  the  practitioner  not  to  have  recognized, 
beforehand,  the  actual  conditions,  though,  to  be  sure,  this  is  a 
very  difficult  thing  to  do,  in  many  cases,  and  sometimes  is  im- 
possible. Organic  fusions  of  the  crowns,  however,  may  be 
recognized  in  all  cases,  by  the  fact  that  it  is  impossible  to  sepa- 
rate them  by  the  ordinary  mechanical  means  (caoutchouc, 
wedges  of  wood,  &c.).  When  the  union  either  by  fusion  or  co- 
alition involves  the  roots,  it  cannot  be  recognized  except  by  an 
attempt  at  extraction,  when  it  will  be  seen  that  the  adjacent 
tooth  is  moved  at  the  same  time  with  the  one  which  is  being 
extracted,  a  circumstance  that  does  not  escape  the  observation 
of  a  careful  operator,  who  is  enabled  thereby  to  suspend  the 
operation  at  an  opportune  moment,  in  cases  in  which  there  may 
be  important  reasons  for  the  retention  of  the  adjacent  tooth, 
and  the  circumstances  admit  of  a  delay  in  the  operation  or 
allow  it  to  be  abandoned  altogether. 

e.  Malfonnations. — These  comprise  irregularities  of  structure 
which  involve  the  w'hole  tooth  or  its  greater  portion,  whereby 
its  proper  form  is  more  or  less  lost  and,  sometimes,  it  is  changed 
into  a  shapeless  mass.  Collections  of  such  teeth  form  a  series 
of  most  remarkable  deformities  which  are  not  merely  of  histo- 
genctic  interest,  but  which  it  is  necessary  for  a  practitioner  to 


IRREGULARITIES    OF    STRUCTURE.  155 

be  able  to  recognize,  since,  in  very  rare  cases,  it  devolves  upon 
him  to  decide  whether  certain  formations  are  dental  structures. 
In  some  respects,  under  this  head  should  also  be  classed  super- 
numerary teeth  which  have  been  considered  in  connection  with 
excess  in  the  number  of  teeth,  in  accordance  with  common  prac- 
tice :  these  are  distinguished  not  so  much  by  an  irregularity  of 
structure,  or  of  the  relations  of  the  arrangement  of  the  dental 
tissues,  but  rather  by  deviation  in  their  external  conformation, 
so  that  they  cannot  properly  be  classified  with  any  of  the  dif- 
ferent kinds  of  teeth.' 

The  malformations  of  teeth  have  their  analogies  in  other 
organs ;  in  extremely  rare  cases  they  involve  the  ivlwle  set  of 
teeth;  but  generally  are  limited  to  separate  ones.  Heider  ob- 
served, in  one  instance,  a  very  remarkable  malformed  set  of 
teeth.  In  the  place  of  the  upper  and  lower  incisors,  canines, 
and  bicuspids,  there  were  throughout  roundish,  large,  pisiform, 
hard  formations  covered  with  fine  white  enamel,  which  were 
flattened  a  little  only  at  the  points  of  contact  between  the  upper 
and  under  rows. 

The  malformations  may  also  occur  primarily  in  the  soft  parts 
of  the  developing  tooth,  whereby  the  development  of  the  hard 
tissues  becomes  arrested.* 

Their  development  is  still  a  matter  of  uncertainty  in  many 
respects,  and  we  are  able  merely  to  infer  it  from  the  malfor- 
mation already  produced;  the  opportunity  of  tracing  it  anatom- 
ically, in  its  different  stages,  has  been  afforded  only  in  extremely 
rare  cases. 


*  All  deformities  of  this  description  have  been  distinguished  of  late  years 
as  odontomaia,  and  Virchow  (Krankhafte  Geschwiilste,  Bd.  ii)  divides  them 
into  two  classes,  namely,  those  which  are  a  product  of  the  developmental 
period  of  the  teeth,  and  the  so-called  odontomata  interna,  which  make  their 
appearance  after  the  period  of  development.  Broca  (Gaz.  Hebd.  de  Med.  et 
Chir.,  1868)  assumes  four  periods  of  their  formation,  and  divides  them  into 
odontomata  etnhryoplastica,  odontoplastica,  coronoria,  and  radicularia.  The 
cases  under  3  (p.  158)  would  be  classed  with  his  odontomes  odontoplnfttiqncfi, 
and  Broca  states,  that  the  latter  are  to  be  considered  merely  as  deformi- 
ties resulting  from  a  disease  of  the  pulp.  The  absence  of  histological  inves- 
tigations in  his  account  and,  especially,  his  disregard  of  the  history  of  the 
development  of  the  teeth,  aflbrd  an  explanation  of  such  a  misunderstanding. 


156  PATHOLOGY. 

The  malformations  are  confined,  in  most  cases,  to  the  coronal 
portions.  Upon  these,  then,  there  is  found  an  arrest  of  develop- 
ment at  a  stage  prior  to  that  of  their  complete  formation ; 
pathological  processes,  hoAvever,  always  enter  into  both  the 
enamel  and  dentinal  formation,  concerning  the  predisposing 
causes  of  which  we  know  nothing.  The  more  frequent  occur- 
rence of  malformations  of  the  second  and  third  molars  may  pos- 
sibly indicate  that  interruptions  in  the  growth  of  the  bone  in 
length,  a  dislocated  wisdom  tooth,  or  a  deficiency  of  space  in 
general,  exercise  an  influence  upon  the  coronal  formation,  which 
is  productive  of  disease.  The  enamel  organ,  excited  to  too 
great  productive  activity,  or  impeded  in  its  normal  productivity 
or  in  the  direction  of  its  growth,  acquires  manifold  irregular 
sinuosities,  the  calcification  of  the  enamel  cells,  which  probably 
have  never  attained  to  maturity,  is  interrupted,  and  the  forma- 
tion of  enamel  prisms  does  not  occur  everywhere  ;  homogeneous 
resisting  masses  of  a  yellowish  color  and  sometimes  of  a  granular 
structure  occur,  which  are  all  the  more  to  be  regarded  as  rudi- 
mentary enamel,  since,  here  and  there,  they  present  indications 
of  enamel  prisms.  The  enamel  cap,  which  not  infrequently  has 
a  cribriform  appearance,  loses  its  proper  form  more  or  less. 
Sometimes,  also,  an  unusually  protracted  persistence  of  the 
enamel  organ,  especially  when  associated  with  abnormal  devel- 
opment of  the  dentine,  may  have  a  share  in  producing  the 
irregular  enamel  formation. 

Contemporaneous  with  that  of  the  enamel  occurs  a  deviation 
from  the  normal  development  of  the  dentine.  The  dentinal 
germ  acquires  multifarious  papillary  excrescences  containing 
bloodvessels.  The  latter  become  obliterated  as  the  formation 
of  dentine  continues ;  the  connective  tissue,  in  which  they  lie, 
becomes  calcified ;  there  remains,  consequently,  a  system  of 
irregular  calcified  tubes  and  cavities  surrounded  by  dentine. 
The  development  of  the  dentine,  in  many  parts,  is  arrested  at 
the  stage  of  the  formation  of  globules  Avith  interglobular  spaces. 
Frequently  the  globules  are  met  with  in  the  form  of  long  streaks 
in  the  midst  of  well-developed  dentine,  and  also  extending  be- 
tween the  enamel  layers.  When  there  are  multiple  contiguous 
dentinal  formations  within  the  pulp  of  the  malformed  tooth,  the 


IRREGULARITIES    OP    STRUCTURE.  ]57 

cavity  of  the  latter  becomes  reduced,  ultimately,  to  a  cleft-like 
gap  containing,  usually,  the  calcified  remains  of  the  pulp.  The 
canals,  with  their  distinct,  smooth  walls,  within  the  dentine,  give 
to  the  latter  the  appearance  of  vaso-dentine,  and  not  infrequently 
also  of  osteo-dentine. 

The  development  of  the  roots  is  impossible  when  sufficient 
space  is  not  reserved  for  them  in  the  jaw,  or  their  growth  is  in- 
terfered with  by  a  developing  crown  which  lies  behind  them. 
Under  the  latter  circumstances  it  is  evident  that  the  develop- 
ment of  the  cement  is  arrested  at  an  early  stage,  or,  if  it  reaches 
a  more  advanced  stage,  the  cement  terminates  the  malformed 
tooth  in  the  form  of  a  stunted  root. 

Our  knowledge  in  regard  to  the  malformations  of  the  teeth  is 
still  too  limited  to  allow  of  a  systematic  division  of  them.  The 
following  classification,  based  upon  general  appearances,  requires, 
therefore,  still  further  additions  in  order  to  make  it  complete. 

1.  Dwarfish  3falformation  of  the  Croivns  and  Roots. — 
Dwarfish  growth  aifects  the  wisdom  teeth  most  frequently,  and 
occurs  by  itself,  unaccompanied  by  any  other  deformity  [vide 
Fig.  59).  In  a  dwarfish  growth  both  the  stunted  crown  and  the 
roots  are  malformed  (Atlas,  Figs.  30,  31,  32);  in  place  of  the 
pulp-cavities  are  found  fissure-like  spaces;  the  dentine  presents 
evidences  of  various  interruptions  in  its  development,  which  are 
indicated  by  numerous  aggregations  of  globular  masses  towards 
the  enamel  boundary  and,  indeed,  extending  even  into  the 
enamel  in  wide,  sharply-defined  canals.  It  is  probable,  there- 
fore, that,  at  the  time  of  the  primary  formation  of  the  enamel 
cap,  interruptions  in  its  continuity  were  produced  corresponding 
with  the  imperfectly-developed  portions  of  the  dentinal  germ, 
and  the  structureless  lining  membrane  of  the  canals  in  the 
enamel  (Atlas,  Fig.  32)  may  be  regarded  as  possibly  the  re- 
mains of  the  stunted  dentinal  germ.  Osteo-dentine  also  is  met 
with,  interposed  in  the  dentine,  and  may  extend  even  as  far  as 
the  enamel  boundary  and,  here  and  there,  is  invested  by  a  nar- 
row border  of  enamel.  In  such  cases  the  radical  portion  of  the 
pulp  is  not  developed.     J.  Tomes*  observed  a  rare  case  which 

*  Op.  cit.,  p.  229. 


158  PATHOLOGY. 

belongs  to  this  class,  of  an  upper  central  incisor,  irregular  in 
shape,  and  only  one- fourth  the  size  of  the  corresponding  tooth. 

2.  G-eneral  monstrous  development  of  the  Croivn,  with  tvell- 
developed  Roots,  is  illustrated  in  the  Atlas,  Fig.  9.  The  exterior 
of  the  crown  presented  such  colossal  proportions,  in  this  case, 
that  Heider  and  I  were  led  to  question  as  to  its  being  a  human 
tooth.  The  structure  of  the  root  portion,  however,  corresponds 
so  exactly  with  that  of  a  human  upper  molar,  that  we  Avere  de- 
cided in  pronouncing  it  such.  The  roots,  indeed,  are  large ; 
but  it  is  a  frequent  occurrence  to  meet  with  roots  as  large  as 
these  in  association  AA^ith  normal  croAvns.  The  most  prominent 
points  to  be  observed  in  the  crown  are,  the  uniform  longitudinal 
folds  of  enamel,  and  the  thick  layer  of  osseous  tissue  Avhich 
everywhere  invests  the  enamel  folds  and  is  in  immediate  con- 
nection with  the  cement  of  the  root.  It  is  quite  remarkable 
that  a  croAvn  three  centimetres  in  length  and  two  and  a  half 
centimetres  in  breadth  should,  on  the  whole,  present  such  slight 
evidences  of  interrupted  development,  and,  besides,  that  the 
structure  of  the  roots  should  remain  normal.  The  dental  sac 
must  have  required  for  itself  an  extremely  large  space,  and  it  is 
evident  that  the  thick  osseous  layer  still  continued  its  develop- 
ment even  after  the  coronal  eminences  emerged.  Special  con- 
ditions also  must  have  existed  to  prevent  suppuration  and 
necrosis  subsequent  to  the  complete  formation  of  the  crown. 

3.  G-eneral  Malformation  of  the  Croivn  of  a  Molar  with  un- 
developed  Roots,  in  association  ivith  the  deeply  imbedded  Croivn 
of  a  Wisdom  Tooth. — Few  cases  of  this  description  have  been 
recorded  up  to  the  present  time,  since  formerly  no  attention  Avas 
given  to  the  anatomical  examination  of  them.  They  correspond 
with  one  another,  in  so  far  that  the  surface  of  the  crowns,  Avhich 
is  occupied  by  numerous  warty  excrescences,  has  a  convex  out- 
line, AA'hile  the  portion  turned  towards  the  croAvn  of  the  Avisdom 
.tooth  presents  an  impression  as  it  were  of  the  latter  Avhich  not 
infrequently  is  bounded  by  a  rim  of  enamel;  they  are  composed, 
principally,  of  vaso-dentine  cavities  containing,  mostly,  calca- 
reous salts,  and  an  irregular,  sometimes  notably  interrupted, 
formation  of  enamel  folds.  The  pulp-caA'ity  is  apparent,  but  in 
a   rudimentary  condition   of  narrow  cleft-like   channels.     The 


IRREGULARITIES    OF    STRUCTURE.  159 

very  great  clinical  interest  -wliicli  attaches  to  these  cases  leads 
me  to  enter  more  into  particulars  concerning  them. 

A  case  in  point  occurred  in  the  practice  of  Dr.  Jarisch,  Sr.* 
A  female  silk-weaver,  twenty-five  years  of  age,  of  a  weakly 
habit  of  body,  reported  the  appearance  during  the  night  of  a 
tumor  upon  the  side  of  the  angle  of  the  right  lower  jaw.  Later, 
severe  pains  were  felt,  and  a  swelling  was  perceived  in  the  region 
of  the  right  wisdom  tooth,  which  led  to  the  opinion  that  the 
eruption  of  the  tooth  was  in  progress.  This  condition  continued 
two  to  three  months,  and  then,  with  symptoms  of  trismus,  a 
collection  of  pus  was  formed,  which  escaped  upon  the  side  of  the 
neck  through  three  fistulous  openings.  Fifteen  months  after 
the  first  appearance  of  the  tumor,  the  patient  came  under  the 
observation  of  Dr.  Jarisch.  At  this  time  there  was  a  very  ex- 
tensive inflammation  of  the  lower  jaw  and  its  vicinity,  with  pro- 
fuse suppuration  ;  the  bone  was  notably  enlarged.  Emollients 
were  ordered.  After  a  few  days,  the  swelling  had  diminished, 
and  upon  the  right  side,  in  the  region  of  the  wisdom  tooth,  there 
was  found  a  body,  the  size  of  the  end  of  the  little  finger ;  it  was 
pale,  covered  with  pus,  and  when  tapped  upon,  gave  a  sound 
like  enamel.  After  the  inflammation  had  subsided  still  more, 
this  body  was  removed  by  the  forceps,  with  very  little  diflBculty. 
The  parts  having  been  cleansed,  the  Avisdom  tooth  was  brought 
into  view  at  the  bottom  of  the  cavity;  the  probe  could  be  passed 
entirely  around  it,  and  its  crown  exactly  fitted  into  the  base  of 
the  solid  formation  which  was  extracted. f 

The  malformed  tooth,  described  in  the  Atlas,  Figs.  34—38, 
inclusive,  for  the  report  of  which  we  are  indebted  to  Prof. 
Strasky  of  Lemberg,  was  removed  from  the  jaw  of  a  strong 
man,  twenty  odd  years  of  age,  who  presented  a  tumor  of  the 
cheek  on  the  right  side,  Avhich  lasted  for  several  weeks  and  was 
accompanied  by  difficult  deglutition,  trismus,  and  pain.  Strasky 
made  an  examination  of  the  mouth  with  great  difficulty,  as  the 
jaws  could  not  be  separated  more  than  an  inch,  and  found  that 
the  gum  upon   the   aff"ected  side,  from  the  first  bicuspid  poste- 

*  Keported  by  C.  Wedl  in  the  Zeitschr.  der  Gesellschaft  der  Wiener 
Aerzte,  1851. 

f  For  the  anatomical  description  of  this  solid  body,  vide  Atlas,  Fig.  39. 


160  PATHOLOGY. 

riorly,  was  considerably  swollen,  reddened,  sensitive,  and,  on 
pressure  in  direction  of  the  angle  of  the  jaw,  it  yielded  some 
pus.  All  the  wisdom  teeth  were  wanting.  Examination  with 
the  probe  showed  that  the  right  second  molar,  merely  the  rough 
masticating  surface  of  which  had  emerged,  was  loosened.  The 
diagnosis  was  made  of  an  impeded  eruption  of  the  wisdom  tooth, 
and  the  loosened  malformed  tooth  removed,  a  difficult  operation, 
with  so  slight  a  separation  of  the  jaws,  and  the  only  thing  to  be 
done  was  to  turn  the  tooth  over  to  the  outside.  A  considerable 
amount  of  pus  mixed  with  blood  escaped  after  the  extraction  of 
the  tooth.  The  tumor  diminished  rapidly  within  eight  days, 
and  after  a  few  months  the  eruption  of  the  normally-formed 
wisdom  tooth  occurred. 

The  latter  case,  in  its  clinical  history,  is  analogous  to  the 
former ;  the  type  of  the  deformity  also,  in  the  two  cases,  is 
similar ;  ■  in  structure,  the  latter  tooth  is  distinguished  by  the 
fact  that  the  enamel  in  its  numerous  folds  is  of  a  much  higher 
grade  of  development,  and  that  the  osseous  substance  between 
the  enamel  and  dentine  and  in  isolated  spots,  is  perfectly  devel- 
oped ;  consequently,  the  three  hard  dental  tissues  are  more 
perfectly  developed  in  this  case  than  in  the  former. 

A  very  instructive  case  occurred  in  the  practice  of  Dr.  Stein- 
berger,*  where  it  was  difficult  and  particularly  important,  to 
form  a  correct  diagnosis,  because  upon  this  depended  the  decision 
of  the  question,  whether  to  remove  a  portion  of  the  jaw  or  to 
separate  the  morbid  formation  from  the  cavity  in  which  it  was 
imbedded.  The  patient,  a  girl,  eighteen  years  of  age,  presented 
quite  a  large  tumor  upon  the  right  lower  jaw,  extending  from 
the  coronoid  process  as  far  as  the  second  bicuspid  tooth,  and 
two  inches  in  depth.  The  protrusion  of  the  maxillary  wall  was 
much  greater  upon  the  outside  than  upon  the  inside.  The  Avhole 
tumor  was  covered  by  considerably  thickened  mucous  membrane. 
Separation  of  the  jaws  was  impeded  and  painful.  These  inflam- 
matory symptoms  continued  eight  days,  and  resembled  closely 
those  attending  the  eruption  of  a  wisdom  tooth.     Steinberger 


*  Jahresber.  dcs  Vereines  oster.  Zasnarzte,  in  the  deutschen  Vicrteljah- 
resschr.  f.  Zahnh.,  18G9. 


IRREGULARITIES    OF    STRUCTURE.  161 

was  confident  of  the  existence  of  the  latter,  but  was  not  a  little 
surprised  to  find,  on  examination  of  the  jaw,  that  all  the  molars 
on  this  side  were  absent.  According  to  the  statement  of  the 
patient,  the  first  molar  had  been  extracted  several  years  previous 
to  that  time,  while  the  tAvo  others  had  never  made  their  appear- 
ance. As  the  molar  upon  the  right  side  of  the  upper  jaw  caused 
pain  by  pressure  upon  the  swollen  gum  which  was  spread  over 
the  tumor,  the  molars  and  bicuspids  on  the  left  side  of  the  lower 
jaw  were  capped  with  hard  rubber,  which  was  to  be  worn  day 
and  night. 

After  a  few  days,  the  pain  had  quite  subsided,  and  the  inflam- 
matory symptoms  almost  disappeared,  subsequent  to  the  forma- 
tion and  evacuation  of  an  abscess,  but  the  lower  jaw  continued  to 
be  considerably  thickened.  After  three  weeks  had  elapsed,  by 
removing  the  gum  which  covered  the  tumor,  a  yellowish-white, 
solid  body,  with  a  rough  surface,  imbedded  within  the  jaw,  was 
detected  by  means  of  a  probe.  After  this  Steinberger  Avas  as- 
sured that  the  case  was  not  one  of  a  cyst  in  the  bone,  but  of  a 
malformation  of  a  tooth.  In  order,  however,  to  render  the 
diagnosis  still  more  positive,  he  trephined  the  body,  and  gave 
me  a  fragment,  about  two  millimetres  in  diameter,  for  examina- 
tion, and  this  showed  the  essential  elements  of  irregularly-devel- 
oped dentine.*  All  doubts  being  thus  removed,  Dr.  Weinlech- 
ner  decided  to  undertake  the  removal  of  the  malformed  monstrous 
tooth  from  the  mouth.  As  only  a  small  portion  of  the  malfor- 
mation was  exposed  to  view,  the  greater  part  of  it  being  over- 
lapped by  the  alveolar  plates  of  the  jaw,  a  simple  operation  for 
the  extraction  was  out  of  the  question ;  it  was  evident,  that  a 
portion  of  the  jaw  must  be  removed  with  the  chisel.  Weinlechner, 
in  the  first  place,  detached  the  gum  from  the  alveolar  margins 
with  a  scalpel,  and  endeavored  to  separate  the  tumor  from  the 
alveolar  borders  by  means  of  an  elevator.  Then,  with  a  wide- 
expanding  forceps,  he  tried  to  seize  the  mass,  but  without  suc- 
cess, because  the  solid  formation  was  overlapped  upon  the  outside 
by  the  edge  of  the  bone.  Thereupon  he  inserted  a  Serres' 
screw  into  the  hole  previously  made  by  the  trephine,  by  which 
means  he  was  enabled  to  move  the  solid  body,  after  he  had  cut 

*  Deutsche  Vierteljahrssch.  f  Zhlk.,  1869. 
11 


162  PATHOLOGY. 

away  a  portion  of  the  external  alveolar  wall.  Having  enlarged 
the  entrance  to  the  cavity  in  the  vicinity  of  the  coronoid  process, 
by  means  of  chisel  and  hammer,  he  introduced  the  chisel  between 
the  external  bony  wall  and  the  solid  body,  and  by  using  the 
former  as  a  lever,  loosened  the  tumor  and  displaced  it  internally. 
At  the  bottom  of  the  cavity  the  crown  of  the  growing  wisdom 
tooth  was  seen,  so  that  the  diagnosis  was  confirmed  by  the 
operation,  and  the  patient's  jaw  preserved,  though  in  all  prob- 
ability it  would  have  been  sacrificed  had  she  applied  to  a  surgeon 
instead  of  a  dentist.  Such  is  the  account  given  by  Steinberger. 
The  deformed  tooth  is  about  the  size  and  shape  of  a  chestnut. 
The  long  diameter,  from  before  backwards,  measures  29,  the 
heiglit  19,  the  breadth,  from  the  outside  to  the  inside,  18  mil- 
limetres. Its  weight,  when  moist,  is  12.37  grammes,  the  color  a 
clear,  pale  yellow,  the  consistence  apparently  firm;  when  tapped 
with  a  knife-blade,  it  yields  a  clear  tone,  of  a  high  pitch,  like 
that  given  by  a  tooth.  The  upper  surface  is  convex,  and  occu- 
pied by  numerous  masses  of  tuberculated,  small,  resisting, 
yellowish,  globular  excrescences.  The  lateral  surfaces  are 
curved  and  traversed  by  grooves.  The  inferior 
surface  presents  a  cavity  with  a  quadrangular 
border ;  this  is  situated  somewhat  to  the  out- 
side, and  obliquely  ;  is  three  to  four  millimetres 
in  depth,  and,  in  size  and  shape,  corresponds 
Avitli  that  of  the  crown  of  a  lower  molar  (Fig. 
'^:  y       Q6).     Tliat  portion  of  the  surface  of  the  cavity 

_^        which  faces  outwards  has  a  smooth  appearance, 
while  that  portion  which  is  directed  inwards  is 
studded  with  several  quite  large  and  many  small  excrescences 
similar  to  enamel  nodules. 

Delicate,  firmly-adherent  fringes  are  attached  to  the  entire 
periphery  of  the  malformation,  excepting  to  the  cavity  in  its 
under  surface.  In  several  places,  short  strips  of  a  thin  mem- 
brane, which  is  intimately  united  with  the  superficial  layer  of 

*  Fig.  66. — Malformed  crown  of  the  second  lower  molar  on  the  right  side. 
The  cavity  was  produced  by  the  crown  of  the  wisdom  tooth  which  was  located 
beneath  it.  Natural  size.  (For  the  use  of  this  specimen  the  author  is  in- 
debted to  Dr.  Steinberger.) 


IRREGULARITIES    OF    STRUCTURE. 


163 


the  solid  body,  spread  over  the  peripheral  warty  excrescences. 
Interlacing  bundles  of  Avavy  connective  tissue  form  the  principal 
constituent  of  the  fringed  membranous  investment,  which  con- 
tains within  its  tissue  collapsed  capillary  bloodvessels  with 
oblong  nuclei  longitudinally  disposed,  the  larger  presenting  also 
nuclei  running  in  transverse  directions.  Besides  these,  sharply- 
defined,  bifurcating,  here  and  there  closed  tubes,  lined  with  a 
layer  of  cells  like  epithelium,  are  also  met  Avith.  In  a  few 
places,  flattened  papilliform  excrescences  are  to  be  seen,  which 
present  upon  their  external  surfaces  rows  of  cells  terminating 
in  pointed  extremities,  and  suggestive  of  dentinal  cells.  Finally, 
in  many  localities,  tolerably  large  flattened  cells,  with  large 
nuclei,  occur,  in  regard  to  Avhich,  also,  it  is  still  undetermined, 
Avhether'they  belong  to  the  rudimentary  gelatinous  layer  of  the 
enamel  organ  [Organ  adamantince). 

Polished  sections  of  the  tooth,  made  by  sawing  through  it  in 
its  longitudinal  axis,  show  no  pulp-cavity,  but  merely  a  number 
of  hard  formations  Avhicli  inclose  a  central  mass,  visible  even  to 
the  naked  eye,  but  more  clearly  appreciated  by  means  of  a  lens; 
these  hard  formations  penetrate  from  the  surfiice  into  the  sub- 
stance of  the  tooth,  are  Avell  defined,  and  terminate  like  a  shut 
sac ;  in  cross-section,  they  present  a  variety  of  shapes  betAveen 
circular  and  oval,  and  are  mutually  adapted,  one  to  another. 

Thin,  ground  sections  aff"ord  a  more  definite  idea  of  the  textural 
relations  (Fig.  67).  The  three 
dental  tissues  are  apparent, 
though  their  distribution  is  quite 
abnormal.  The  principal  mass 
is  composed  of  dentine,  the  ca- 
nals of  Avhich,  in  varying  num- 
bers, radiate  from  cavities  (the 
central  masses  of  the  above- 
mentioned  mutually  adapted 
hard     formations),    and,     after 


Fifi.  67* 


*  Fig.  67. — Segment  of  a  transverse  section  from  the  same  malformed 
crown.  The  dark  streaks  extending  in  different  directions  are  the  remains 
of  the  pulp  around  which  the  systems  of  dentinal  canals  are  grouped. 
Magnified  10  diameters. 


16-i  PATHOLOGY. 

traversing  a  loncrer  or  shorter  distance,  become  lost  to  view  in 
the  peripheral,  abundant,  globular  masses  which  invest  the 
system  of  canals,  or  more  often  in  the  interglobular  spaces,  after 
numerous  dichotomous  divisions.  Here  and  there,  the  neighbor- 
ing systems  of  dentinal  canals  unite  and  decussate  with  each 
other.  The  arrangement  and  course  of  these  canals  are  quite 
normal,  in  some  localities,  while,  in  others,  they  are  fewer  in 
number,  assume  tortuous  courses  in  great  variety,  and  do  not 
present  the  bushy  appearance  peculiar  to  them.  The  abundant 
globular  masses  not  infrequently  penetrate  to  a  considerable  dis- 
tance between  the  dentinal  layers. 

The  above-mentioned  irregular  cavities  of  various  dimensions 
contain  opaque,  amorphous,  calcareous  salts,  and  are  the  more 
to  be  regarded  as  the  remains  of  the  pulp-cavity,  since  blood- 
stained portions  also  are  met  with.  Besides  these  cavities,  the 
dentine  also  contains  canals,  filled  with  hyaline,  calcareous 
grains  which,  here  and  there,  have  the  appearance  of  being 
still  imbued  with  fresh  blood ;  therefore  a  formation  of  vaso- 
dentine  likewise  occurred,  to  which,  here  and  there,  there  was 
a  continued  supply  of  blood. 

In  the  vicinity  of  the  inferior  excavated  surface,  the  enamel 
presents  very  distinct  nodular  projections,  while,  laterally  also, 
it  is  elevated  into  an  irregular  narrow  ridge.  Irregular  conical 
processes  of  enamel  are  prolonged,  in  many  places,  into  the 
dentinal  layers.  Generally  speaking,  completely  developed 
enamel,  with  longitudinally,  obliquely  and  transversely  divided 
prisms,  is  not  of  frequent  occurrence ;  but  it  is,  for  the  most 
part,  rudimentary  in  character,  composed  merely  of  diffused, 
yellowish  and  dark-brown,  resisting  masses  containing  traces  of 
prisms. 

The  cement  is  more  or  less  distinct  upon  the  upper  convex 
surface  of  the  malformation,  of  unequal  thickness,  and  is  marked, 
here  and  there,  with  indentations,  the  results  of  the  process  of 
resorption.  True  bone-corpuscles,  with  multiradiating  canali- 
culi,  and  a  striated  intercorpuscular  substance,  are  to  be  seen 
in  many  localities,  while  in  others  the  cement  is  retarded  in  its 
development.  Finally,  there  remains  to  be  noticed,  the  occur- 
rence of  one  or  more  groups  of  well-marked  bone-corpuscles 


IRREGULAKITIES    OF    STRUCTURE.  165 

>Yhich  are  interpolated  in  the  neighborhood  of  the  globular  sub- 
stances in  the  deeper  layers  of  the  malformation,  care  being 
requisite  in  order  to  avoid  confounding  interglobular  spaces 
filled  with  calcareous  salts,  with  bone-corpuscles. 

The  origin  of  this  monstrous  tooth  can  only  be  conjectured. 
This  much,  however,  may  with  reason  be  admitted;  that  the  in- 
terlacing of  the  systems  of  dentinal  canals  is  explained  by  the 
existence  of  numerous  new  formations  of  dentine  (odontomes), 
extending  in  various  directions  into  the  pulp;  for  the  same 
reason,  also,  the  pulp-cavity  is  represented  merely  by  cleft-like 
gaps.  From  the  abundant  and  very  irregular  folding  of  the 
enamel  organ,  the  conical  prolongations,  extending  inwards,  re- 
sulted. As  before  observed,  I  agree  with  J.  Tomes,  in  consid- 
ering Nasmytlis  membrane  to  be  a  continuation  of  the  cement 
layer  and,  also,  a  rudimentary  osseous  tissue,  so  that  to  my 
mind,  the  occurrence  of  an  osseous  substance,  in  an  advanced 
stage  of  development,  is  readily  explained. 

There  can  scarcely,  indeed,  be  any  doubt  but  that,  in  this 
case  which,  clinically,  was  carefully  studied,  a  dislocation  of  the 
germ  of  the  wisdom  tooth  occurred  during  the  growth  of  the 
second  molar,  in  consequence  of  a  deficiency  of  space,  whereby 
the  former,  instead  of  assuming  a  position  behind,  became  lo- 
cated beneath  the  second  molar ;  the  subsequent  formation  of 
its  crown  prevented  the  development  of  the  radical  portion  of 
the  molar  tooth  and,  in  all  probability,  was  the  general  exciting 
cause  of  the  whole  mischief.  In  the  imperfectly  formed  crown 
of  the  second  molar,  both  the  dentine  and  enamel,  as  well  as 
the  cement,  became  developed  in  abnormal  directions,  and  the 
growth  of  the  separate  tissues  in  some  parts  was  excessive  and 
in  others  defective.  The  fact,  that  the  growth  of  the  malformed 
tooth  continued  beyond  the  ordinary  period  until  its  eruption,  is 
confirmed  by  the  demonstrable,  well-preserved  bloodvessels  con- 
tained in  the  connective  tissue  fringes  of  the  exterior,  and  that 
the  deformed  mass  was  penetrated  by  the  wisdom  tooth  lying 
beneath  it,  is  indicated  by  the  cavity  presented  by  the  under 
surface  of  the  deformed  tooth,  which  is  a  cast  of  the  crown  of 
the  wisdom  tooth. 


166  PATHOLOGY. 

In  view  of  the  great  interest  of  his  case,  Dr.  Steinberger,  at 
intervals  of  several  months,  prepared  three  plaster  casts  of  the 
surface  of  the  lower  jaw,  and  kindly  loaned  me  the  models. 
The  illustrations  given  in  Figs.  68  and  69  correspond  with  the 

Fig.  68*  Fig-  C9.t 


first  two  periods  and  show  the  variation  in  the  cavity,  which 
was  occupied  by  the  malformed  tooth,  and  the  change  in  the 
position  of  the  wisdom  tooth. 

If  a  horizontal  plane  be  projected  posteriorly  from  the  masti- 
cating surface  of  the  second  bicuspid  tooth,  and  the  distance 
from  the  posterior  coronal  border  of  the  latter  to  the  anterior 
border  of  the  wisdom  tooth,  in  the  visual  plane,  in  other  words, 
if  their  distance  from  each  other  upon  the  longitudinal  plane, 
at  the  first  period,  be  measured  and  compared  with  the  distance 
at  the  second  period,  it  will  be  found,  that  the  longitudinal  dis- 

*  Fig.  68. — Plaster  cast  of  a  right  half  of  a  lower  jaw,  showing,  posterior 
to  the  alveolar  cicatrix  of  the  first  molar,  a  cavity  from  which  the  malformed 
second  molar  was  removed  by  operative  means.  At  the  bottom  of  the  cavity 
maj'  be  seen  the  wisdom  tooth  displaced  to  one  side.  The  cast  was  taken 
soon  after  the  operation.     Two-thirds  natural  size. 

f  Fig.  69. — Plaster  cast  of  the  same  segment  of  the  right  lower  jaw, 
taken  several  months  after  the  removal  of  the  malformed  tooth.  The  di- 
mensions of  the  cavity  have  diminished,  and  the  crown  of  the  wisdom  tooth 
has  reached  a  higher  level  and  moved  towards  the  median  line.  Two-thirds 
natural  size.  (For  the  use  of  both  casts  the  author  is  indebted  to  Dr.  Stein- 
berger.) 


IRREGULARITIES    OF    STRUCTURE.  167 

tance  between  the  two  teeth  =  sixteen  millimetres  has  remained 
unchanged,  but  that  on  the  other  hand,  the  masticating  surface 
of  the  wisdom  tooth  has  been  raised  about  nine  millimetres  and 
lies  only  three  millimetres  below  the  level  of  the  second  bi- 
cuspid. The  wisdom  tooth,  however,  has  also  been  displaced 
from  the  outside  inwards,  so  that  it  is  but  a  few  millimetres  to 
the  outside  of  its  normal  position.  The  dimensions  of  the  cavity 
present  a  considerable  diminution  in  the  later  period ;  the  lon- 
gitudinal diameter  being  about  twelve  millimetres,  the  transverse 
about  six  millimetres  ;  the  approximation  of  the  facial  to  the 
lingual  maxillary  wall  has  been  brought  about  by  the  process  of 
cicatrization,  the  contraction  of  the  cavity  being  analogous  to 
that  of  the  alveoli  subsequent  to  the  extraction  of  teeth. 

J.  Tomes*  reports  a  very  similar  case.  The  deformed  molar 
of  the  lower  jaw,  likewise  located  over  the  wisdom  tooth,  was 
several  times  larger  than  the  latter,  the  development  of  which 
Avas  retarded.  The  nature  of  the  case  was  not  rightly  under- 
stood, consequently  a  portion  of  the  jaw  was  removed. 

Analogous  malformations  are  met  with  in  animals,  and  have 
been  observed  in  the  horse  by  Etienne  Geoffroy  St.  Hilaire, 
and  Rousseau.  I  am  indebted  to  Prof.  Bruckmiiller,  of  the 
Vienna  Veterinary  Institute,  for  an  extremely  rare  example  of 
a  malformed  left  molar  from  a  horse.  The  colossal  tooth  at- 
tained about  the  size  of  an  orange  and,  evidently,  was  located 
within  the  dental  range,  for  upon  the  anterior  and  posterior  sur- 
faces are  to  be  seen,  in  directions  oblique  to  each  other,  the 
abraded  surfaces  produced  by  friction  with  the  contiguous  sur- 
faces of  the  adjacent  molars.  The  monstrous  formation  pre- 
sents one  surface,  convex,  rough,  studded  with  numerous  denta- 
tions, and  another,  excavated,  and  polished  in  appearance, 
corresponding  to  the  masticating  surface.  The  latter  presents 
a  substance  composed  of  enamel  and  dentine,  which  is  trans- 
versely disposed  from  the  outside  to  the  inside,  one  to  five  mil- 
limetres in  width,  sharply  defined,  and  divides  the  excavation 
into  two  unequal  portions. 

The  remainder  of  the  tooth  is  composed  of  finely  porous  osse- 

*  Op.  cit,  p,  2L'4. 


168 


PATHOLOGY. 


ous  substance  and  dentine. 


Fig.  70* 


The  enamel  extends  from  the  masti- 
cating surface  (Fig.  70), 
into  the  substance  of  the 
tooth,  where  it  forms  nar- 
row zigzag  folds,  which 
are  accompanied  by  the 
dentine.  Towards  the 
lower  portion,  the  periph- 
eral cement  penetrates 
to  various  depths.  The 
pulp-cavity  is  wanting, 
its  upper  portion  being 
filled  with  osteo-dentinal 
masses,  which  distend  the 
Avails  of  the  cavity. 

4.  J.  Tomesf  also  mentions  partial  deformities  of  the  croum 
in  the  form  of  excrescences.  An  outgrowth  of  this  kind  came 
under  his  observation,  upon  the  anterior  surface  of  an  upper 
central  incisor,  and  consisted  of  imperfectly  developed  and  ir- 
regularly arranged  dental  tissues.  He  also  states,  that  a  case 
described  by  Salter  in  the  "Pathological  Transactions,"  under 
the  title  of  a  "Warty  Tooth,"  comes  under  this  head. 

5.  Fissures. — During  the  development  of  the  tooth,  it  hap- 


*  Fig.  70  shows  a  carious,  malformed  left  molar  from  a  horse.  (For  this 
specimen  the  author  is  indebted  to  Prof.  Bruckmiiller.)  Sagittal  section. 
The  smooth,  masticating  surface  (a)  has  a  polished  appearance,  is  deeply  ex- 
cavated and  divided  into  two  unequal  portions  by  a  substance  composed  of 
enamel  and  dentine,  which  extends  from  below  upwards.  One  of  the  two 
abraded  surfaces,  produced  by  friction  with  the  anterior  and  posterior  adja- 
cent teeth,  is  visible,  [b).  The  osseous  substance  is,  comparatively,  more  abun- 
dant than  the  other  tissues,  and  forms  the  mass  lying  upon  either  side,  like 
a  kernel  in  a  shell,  in  which  mass  are  imbedded  striated  markings  of  dentine, 
(c)  At  the  outer  part  of  the  substance  forming  the  shell,  osseous  tissue 
(rf,  d)  is  met  with,  which  is  united  with  irregular  folds  of  enamel  (c),  and  in- 
ternally to  the  latter,  with  dentine.  Confused  masses  of  dentinal  tissue  (/), 
however,  which  are  traversed  by  canals,  are  met  with,  also,  in  immediate 
connection  with  the  cement.  The  occurrence  of  caries  upon  the  superficial 
portion  of  the  grooved  masticating  surface  has  left  jagged,  discolored  cav- 
ities.    Two-thirds  natural  size. 

t  Op.  cit.,  p.  227. 


IRREGULARITIES    OF    STRUCTURE.  169 

pens,  sometimes,  that  the  continuity  of  the  enamel  cap  becomes 
interrupted,  and  the  dentine  appears  to  penetrate  into  the  cleft- 
like gaps  of  the  enamel.  The  dentine,  also,  is  developed  beyond 
its  normal  limits  in  many  places,  and  hence  another  source  of 
cleft-formations.  The  fissures  in  the  enamel  are  sharply  cut  and 
filled  with  dentinal  globules  (Atlas,  Fig.  32).  In  most  cases, 
the  growth  of  the  dentine  does  not  extend  into  the  fissures, 
and  we  find  merely  cleft-like  gaps  in  the  substance  of  the  en- 
amel cap. 

The  dentine  may,  however,  attain  a  higher  grade  of  develop- 
ment in  the  fissures,  as  is  illustrated  by  Fig.  33  in  the  xVtlas, 
where  the  crown  and  root  of  a  wisdom  tooth  present  an  appear- 
ance as  if  they  had  been  divided  by  a  longitudinal  section,  and 
a  flattened  plate  of  dentine  had  been  introduced  into  the  fissure, 
where  it  had  continued  to  grow  and  become  firmly  adherent. 
Fissures  in  the  roots  are  due  to  defective  union  of  the  two  rad- 
ical halves.  A  fissure  in  the  neck  extending  into  the  root- 
canal,  and  surrounded  by  a  layer  of  enamel  which  extends 
perhaps  to  the  bottom  of  the  cleft  (Atlas,  Fig.  27),  sometimes 
occurs,  though  it  is  extremely  rare. 

6.  Monstrous  outgrowth  of  Dentine  and  Cement  [osteo-odon- 
toma)  upon  the  Root. — Rare  tumors  of  this  description  are  de- 
veloped, during  the  formation  of  the  roots,  from  a  circumscribed 
portion  of  the  radical  pulp.  The  hard  tissues  of  the  tumor 
comprise  bone  and  dentine,  but,  as  the  crown  is  not  involved, 
enamel  is  not  found  (Atlas,  Figs.  28  and  29).  The  cortical 
tissue  of  the  tumor  is  composed  of  cement,  beneath  which  is 
found  a  comparatively  thin,  but  normally  formed  layer  of  den- 
tine ;  immediately  internal  to  the  latter  expands  the  abundantly 
vascularized  osseous  mass  which  forms  the  principal  component 
of  the  tumor  and,  from  the  fact  that  it  is  encompassed  by  den- 
tine, must  have  originated  from  the  pulp  of  the  root.  Heider,* 
who  previously  described  this  malformation,  was  inclined  to 
regard  it  as  an  instance  of  the  fusion  of  a  normally  formed 
wisdom  tooth  with  a  malformed  supernumerary  dental  germ.  In 
my  opinion,  the  supposition  of  a   supernumerary  dental  germ 


*  Mittheiluniren  des  Centralv.  deutsch.  Zahiiiirzte,  1860. 


170  PATHOLOGY. 

cannot  be  entertained,  from  the  fact  of  the  entire  absence  of  all 
traces  of  enamel  in  the  tumor.  Heider  was  unable  to  obtain 
any  history  of  the  case. 

Th.  Billroth  reported  a  case  "which  may  be  classed  under  this 
head,  from  Langenbeck's  Clinic  in  Berlin.*  A  girl,  sixteen 
years  of  age,  complained  for  several  months  of  a  swollen  and 
painful  cheek  on  the  right  side.  During  the  same  period,  the 
second  right  (large  ?)  molar  of  the  upper  jaw  acquired  an  ob- 
lique position  and  a  slight  displacement  inwards,  and  at  the 
same  time,  a  hai^d  mass  made  its  appearance  upon  the  outside, 
which  the  patient  supposed  to  be  another  tooth.  She  was 
utterly  ignorant  as  to  the  length  of  time  during  which  the  latter 
irregularity  had  existed.  On  examination,  the  external  wall  of 
the  antrum  was  found  to  be  distended,  where  an  indistinctly 
defined,  hard  tumor,  the  size  of  a  walnut,  could  be  felt.  Neither 
the  tooth  nor  tumor  were  movable.  With  a  stout  Eno-lish  for- 
ceps,  both  were  seized  and  extracted  together.  The  mass  was 
of  a  bony  hardness,  the  size  of  a  walnut ;  its  upper  surface  was 
very  uneven,  warty,  and  entirely  destitute  of  soft  parts,  the 
whole  tumor  presenting  an  appearance  as  if  it  had  been  wedged 
into  a  sort  of  large  alveolus.  The  tooth  was  firmly  attached  to 
the  tumor,  its  roots  apparently  being  entirely  imbedded  in  the 
new  formation.  No  second  crown  could  be  discovered  any- 
where. The  surface  of  a  section  resembled  very  much  the  pol- 
ished surface  of  an  agate.  Microscopical  examination  showed 
it  to  be  made  up  principally  of  dentine,  with  cavities  and  canals, 
and  bone-corpuscles,  which  were  of  extremely  irregular  forms. 
No  enamel  was  to  be  found. 

7.  Double  or  Twin-formations. — The  essential  characteristic 
of  these  is,  that  instead  of  a  single,  there  is  formed  a  double 
dental  germ,  Avhich  remains  inclosed  in  a  single  dental  sac,  and 
as  a  result  of  this,  a  partial  or  complete  fusion  of  the  twin- 
formations  ensues.  There  are,  consequently,  two  crowns  and 
two  radical  portions  belonging  to  the  same  kind  of  tooth. 
Herein  lies  the  distinction  between  twin-formation  and  the 
fusion  of  two  teeth.     Sometimes  the  development  of  one  of  the 


*  Yiichow's  Archiv.,  Bd.  viii. 


IRREGULARITIES    OF    STRUCTURE.  171 

pair  is  considerably  retarded,  and,  ultimately,  it  may  present 
such  a  deformity,  that  the  form  of  the  crown,  or  root,  -which  should 
denote  the  kind  of  teeth  to  which  it  belongs,  is  unrecognizable, 
and,  therefore,  the  basis  is  lost  for  determining  whether  or  not 
the  case  is  one  of  twin-formation. 

The  only  cases  of  twin-formation  in  man,  as  far  as  I  know, 
which  have  been  observed  up  to  the  present  time,  are  those  of 
wisdom  teeth,  and  such  a  one  is  described  in  the  Atlas,  Fig. 
20.  "Whether  they  occur  with  other  kinds  of  teeth  is  a  question 
to  be  decided  by  more  extended  investigations.  Animals,  also, 
occasionally  present  deformities  of  this  kind,  and  A.  Friedlow- 
sky  reported*  an  instance  of  twin-formation  of  the  left  tusk  of 
an  elephant,  the  one  on  the  right  side  being  stunted  in  its 
grow'th  ;  the  former  is  composed  of  two  of  unequal  size,  the 
larger  of  which  is  wound  around  the  smaller  in  the  form  of  a 
long  spiral  ;  the  anterior  segments  of  both  roots  and  the  greater 
portion  of  the  bodies  are  fused  together,  but  the  apices  of  the 
tusks  are  separate. 

8.  The  parenchyma  of  the  embryonic  dental  pulp  degene- 
rates in  various  Avays  which  are  imperfectly  understood.  The 
unique  case  observed  by  Robinf  may,  as  Virchow|  states,  be 
regarded  as  one  of  fibrous  degeneration  ;  in  this  case,  there 
Avas  found  upon  the  lower  jaw  of  a  child,  two  and  a  half  years 
of  age,  apparently  a  fibrous  tumor,  in  Avhich  papilliB  with  quite 
distinct  dentine  and  enamel  could  be  recognized. 

VirchoAV  designates  Leisering's  case,  observed  upon  the 
lower  jaw  of  a  calf,  as  a  myxomatous  proliferation  of  the  dental 
germ.  This  was  developed  in  the  vicinity  of  the  sixth  molar, 
forced  the  dental  wall  asunder,  and  made  its  appearance  as  a 
free  polypoid  tumor,  three  inches  in  length  and  seven  and  a 
half  inches  in  breadth.  It  presented  upon  its  surface  papilliTe, 
which  here  and  there  were  covered  with  quite  firm  enamel  and 
dentine  and,  besides,  was  composed  of  connective  tissue,  blood- 
vessels, dentinal  cells,  &c. 

9.  A  very  remarkable  series  of  phenomena  is  presented  by 

*  Sitsungsber.  der  Wien.  Akad.  d.  Wiss.,  1869. 
f  Mem.  de  la  Soc.  de  Biologie,  1863. 
J  Krankhafte  Gescliwiilste,  Bd.  ii,  p.  57. 


172 


PATHOLOGY. 


dentigerous  cysts,  where  several  germs,  belonging  to  the  same 
kind  of  teeth,  (?)  are  contained  within  a  capsule  of  connective 
tissue.  Nelaton  found  eight  bodies  in  a  dental  cyst,  and  pro- 
nounced the  case  one  of  multiple  dental  formations  within  a 
sino;le  alveolus.  Broca  modified  the  latter  view,  and  asserted 
that  the  eight  bodies  were  not  dental  follicles,  but  dental  germs 
which  arose  from  an  eight-fold  division  of  the  original  dental 
germ. 

Imperfectly  Developed  Teeth  in  a  3Iultilocular  Ovarian  Cyst. 
— In  concluding  the  subject  of  anomalies  of  formation,  I  will 
add  some  observations  with  reference  to  teeth,  which,  though 
they  do  not  come  within  the  province  of  the  dentist,  still  deserve 
an  interest  on  his  part ;  but  I  must  express  my  regret  that  I 
have  been  unable  to  obtain  more  than  the  following  single  case 
of  teeth  in  ovarian  cysts.  Dr.  Weinlechner  extirpated,  with  a 
successful  result,  a  multilocular  ovarian  cyst,  about  the  size  of 
the  fist.  The  largest  cyst,  oval  in  shape,  measured  7.5  cen- 
timetres, in  its  long  diameter,  and 
Fig.  71.*  iuclosed  a  disk  of  bone  twenty- 

seven  millimetres  in  diameter, 
attached  to  a  cushion  of  dermal 
tissue  which  was  the  seat  of  a 
growth  of  hair.  Into  this  disk 
are  inserted  three  teeth  which  are 
surrounded  by  a  fold  of  mucous 
membrane.  The  contiguous  ex- 
ternal skin  may  be  divided  into 
two  portions,  one  covered  with 
woolly  hair  and  flattened,  conical, 

*  Fig.  71  shows  three  upper  teeth  implanted  in  a  slightly  convex  disk  of 
bone  and,  behind  these,  a  pad  of  skin  with  long  hairs.  Taken  from  a  multi- 
locular ovarian  cyst.  The  middle  tooth  is  the  largest;  its  crown  corresponds 
with  that  of  a  permanent  molar ;  its  roots,  resembling  those  of  wisdom  teeth, 
are  bent  in  the  shape  of  a  bow.  The  long  diameter  of  the  oblong  crown 
measures  eleven,  and  the  short  diameter  eight  millimetres.  The  adjacent 
milk  molar  to  the  left  has  an  inclined  position  ;  that  to  the  right  also  cor- 
responds with  a  milk  molar.  The  three  teeth  are  surrounded  by  a  smooth 
mucous  membrane,  which  extends  to  the  pad  of  dermal  tissue  and  becomes 
continuous  with  the  external  skin  which  is  furnished  with  hair.  Natural 
size. 


IRREGULARITIES    OF    STRUCTURE.  173 

comparatively  large  papilloe,  and  the  other  furnished  Avith  tufts 
of  glossy,  dark  pigmented  hair.  This  dermal  tissue  presents  a 
thickness  of  four  millimetres  in  its  thickest  portion,  and  is  con- 
tinued in  the  form  of  a  thin  layer  over  the  cyst-wall,  the  latter 
being  about  one  millimetre  or  less  thick.  Numberless  hairs  also 
are  implanted  everywhere  in  the  thin  layer  of  skin. 

By  the  removal  of  the  periosteal  layer  of  the  bone  together 
with  the  hairy  cushion  of  skin,  a  very  singularly-formed  osseous 
framework  was  brought  into  view  beneath,  forming  a  continua- 
tion of  the  osseous  plate  into  which  the 
three  upper  teeth  are  inserted  (Fig.  72). 
This  plate,  which  is  to  be  considered  as 
the  rudimentary  upper  jaw,  presents  an 
outer,  i.  e.,  turned  towards  the  cyst-wall, 
convex  and  smooth,  and  an  inner,  con- 
cave, uneven  surface.     Upon   the   latter 
project  the  roots  of  the  teeth.     Upon  the  "     '^ 

continuation  of  the  osseous  framework  behind  the  rudimentary 
upper  jaw  rise  two  perpendicular,  tolerably  thick,  compact, 
slightly  curved,  osseous  laminpe,  which  terminate  in  blunt- 
pointed  processes  that  incline  towards  each  other.  The  basal 
portions  of  the  laminte  are  united  in  the  direction  of  the  dental 
plate  and  partially,  also,  upon  the  opposite  side ;  and  hence  an 
incomplete  excavation  is  formed,  which  is  filled  with  an  unctuous, 
fatty  mass  (cerebral?),  and  lined  with  a  separablefibrous  mem- 
brane ;  adherent  to  the  anterior  portion  of  the  excavation  are 
two  black  pigmental  masses  of  lax  connective  tissue,  the  size  of 
millet-seeds,  containing  several  groups  of  epithelium  cells  with 
black  pigment  together  with  cords  containing  pigment  (belonging 
to  the  choroidea?).  Several  apertures  also  found  here  probably 
serve  for  the  passage  of  bloodvessels  and  nerves. 

In  two  other  cysts  rudimentary  fragments  of  the  jaw  were 
found  in  the  form  of  osseous  plates  in  which  teeth  were  implanted. 


*  Fig.  72  shows  an  osseous  framework  presented  by  the  previous  specimen. 
Posterior  view,  a,  a,  blunted,  convergent,  terminal  extremities  of  the  two 
elevated  osseous  laminae.  At  the  bottom  of  the  cavity  are  three  apertures 
for  the  transmission  of  bloodvessels  and  nerves.     Natural  size. 


174  PATHOLOGY. 

The  larger  plate  has  a  discoid  form,  a  diameter  of  nearlj''  two 
centimetres,  and  is  from  0.5  to  4  millimetres  thick.  The  ex- 
terior surface,  i.  e.,  the  surface  turned  towards  the  cjst-wall,  is 
smooth  and  slightly  convex,  while  the  interior  is  occupied  by 
several  irregular  osseous  protuberances.     From  one  sharp  edge 

of  the  plate  projects  the  crown  of  a 
milk  molar  (Fig.  73),  which,  on  close 
inspection,  presents  a  defect  in  the 
enamel ;  the  outer  segment  of  the 
crown  and  roots,  also,  is  wanting,  and 
a  gives  to  it,  w^ien  viewed  from  the  ex- 
ternal wall  of  the  plate,  the  appear- 
ance as  if  it  had  been  split  longitudi- 
nally. Upon  the  other  side  of  the 
plate  rises  a  perpendicular  process  of  bone  which  has  a  cylindri- 
form  shape,  is  excavated  at  the  upper  part  and,  upon  one  side 
of  its  base,  presents  a  shallow  cavity  which  is  traversed  by 
several  osseous  trabcculiB.  Upon  either  side  of  the  process  is  a 
minute  foramen  and  a  groove  for  the  afferent  bloodvessels  and 
nerves.  The  greater  portion  of  the  osseous  plate,  in  this  case, 
as  in  the  one  previously  described,  was  covered  with  a  cushion 
of  skin  and  a  growth  of  hair. 

Again,  in  a  third  cyst,  with  a  small,  flattened  fragment  of  the 
upper  jaw,  two  teeth,  in  this  case  still  concealed  Avithin  the  gum, 
were  found,  next  to  a  tegumentary  cushion,  having  conical 
papillce  flattened  upon  two  sides  and  covered  with  hair.  The 
membrane  stretching  over  the  crown  presents  an  appearance 
exactly  like  that  which  is  found  at  the  time  of  the  eruption  of  a 
normal  tooth,  that  is  to  say,  clouded  interlacing  bundles  of 
fibrous  tissue,  without  perceptible  vessels,  and  nuclei,  form  the 
principal  portion.  One  of  the  teeth,  a  bicuspid  (Fig.  74), 
presents  a  hook-like  bend  at  the  extremity  of  the  root,  and  a 
notable  peculiarity.     If,  namely,  the  general  course  of  the  thin 

*  Fig.  73  shows  an  osseous  plate  taken  from  a  second  cyst  of  the  same 
ovary.  View  of  the  internal  surface  directed  towards  the  cyst-cavitj-.  At 
(a)  is  inserted  an  imperfectly-developed  lower  milk  molar  ;  [h),  perpendicular 
process  of  bone  (rudimentary  ascending  ramus  of  the  lower  jaw).  Natural 
size. 


IRREGULARITIES    OF    STRUCTURE.  175 

cement  be  traced,  it  will  be  seen,  that  it  invaginates  the  dentine 
near  the  extremity  of  the  root,  where  it  is  continued  as  a  sharply- 
defined   luminous    zone   (globular    masses 
with    interglobular    spaces)    between    the  ^""  'i* 

outer  and  inner  dentinal  segments.     The  '  '  ' 

dentinal  canals,  commencing  at  the  pulp-  '> - 

cavity,  terminate  at  the  luminous  zone  in 

anastomotic  loops,  or  in  its  interglobular  [  ;  •  f^-"^^' 

spaces.     The  pulp-cavity  and    canal   are 
of  nearly   equal    breadth,    and  inclose   a      ! 
pulp,  presenting  the  condition  of  net-like      ' 
atrophy.     The  enamel  is  well  developed. 
In  my  opinion,  the  condition  presented  by 
the  dentine,  in  this  case,  is  an  indication 

of  the  occurrence  of  an  interruption  to  the  dentinal  develop- 
ment ;  in  the  interval,  the  process  terminated  with  the  forma- 
tion of  globular  masses,  and  subsequently  the  growth  of  den- 
tine ensued  in  a  regular  manner.  The  second  milk  molar  of 
the  same  cyst  presents  upon  its  neck  a  distinct  defect,  with 
sharp  edges,  in  appearance  as  if  a  file  had  been  used  upon  the 
crow^n.  A  sclerosed,  clouded  mass  of  connective  tissue  was  ad- 
herent at  this  point.  Without  doubt,  more  extended  investiga- 
tions, with  reference  to  the  teeth  contained  in  ovarian  cysts, 
will  prove  a  fertile  field  for  the  study  of  anomalies  of  teeth. 
The  imperfectly-developed  bicuspid  mentioned  by  Richard  Owen"}" 
also  presents  an  anomalous  formation  similar  to  that  of  the  upper 
bicuspid  in  the  figure. 

*  Fig.  74  shows  a  section  of  an  upper  bicuspid  from  a  third  cyst  of  the 
same  ovary.  The  crown,  neck,  and  commencing  portion  of  the  root  are 
well:  developed.  The  apex  of  the  root  presents  a  strong  flexion.  In  general 
the  tooth  has  an  ajipearance  as  if  a  fresh  cylindrical  piece  of  dentine  had 
been  inserted  into  the  tooth  prior  to  the  closure  of  its  root.  Magnified  4 
diameters. 

f  Odontography,  Plate  124. 


176  INFLAMMATIONS. 


11.  IXFLAMMATIOXS. 

Dental  Pulp. — When  we  consider  the  great  amount  of  ill 
usao'e  to  which  the  teeth  are  subjected,  Ave  may  well  wonder  that 
primary  or  idiopathic  inflammations  of  the  pulp  are  not  of  more 
frequent  occurrence.  J.  Tomes  goes  so  far  even  as  to  say  that, 
in  ninety-nine  out  of  a  hundred  cases,  the  diseased  action  is  con- 
sequent upon  perforation  of  the  pulp-cavity  by  caries.  Heider,* 
also,  expresses  a  similar  opinion. 

The  difficulties  attending  the  recognition  of  an  idiopathic  in- 
flammation are  rendered  still  greater  from  the  fact  that,  in 
making  the  diagnosis,  caries  is  to  be  excluded,  and  this  is  a 
difficult  matter  to  determine  in  not  a  few  cases.  Again,  an  in- 
flammation of  the  periosteum  of  the  root  may  be  misinterpreted 
as  one  of  the  pulp.  A  third  element  of  difficulty  lies  in  dis- 
tinguishing between  a  commencing  inflammation  and  the  hyper- 
aesthesia  of  the  pulp  which  is  occasioned  by  a  congestive  condi- 
tion. When  the  objective  symptoms  are  Avanting  and  it  becomes 
necessary  to  depend  upon  the  subjective  ones  exclusively,  then 
the  course  which  the  disease  takes  can  only  decide  the  point. 
If  the  aff'ection  presents  decided  intermissions,  and  hypera?sthesia 
of  other  organs,  also,  occurs,  there  will  be  good  grounds  for 
excluding  inflammation. 

If  Ave  trace  the  history  of  an  inflammation  of  the  pulp,  occa- 
sioned by  so-called  perforating  caries,  and,  first  of  all,  the  pain, 
it  Avill  be  found  that  the  latter  is  localized  primarily,  and  sub- 
sequently extends  to  the  neighboring  teeth,  and  even  over  the 
whole  side  of  the  face.  The  partially  exposed  pulp  is  sensitive 
to  external  influences  ;  a  current  of  air,  cold  water,  acid  sub- 
stances, Avhen  brought  into  contact  Avith  it,  give  rise  to  painful 
sensations,  while  pressure  upon  the  tooth  is  Avell  borne,  provided 
the  exposed  pulp  is  not  pressed  upon.  The  intensity  of  the 
pain  varies  according  to  the  irritability  and  age  of  the  indi- 
vidual ;  frequently  it  is  more  severe  during  pregnancy  or  at  the 
• 

*  Zeitschrift  der  k.  k.  Gesellsch.  dcr  Wiener  Aerzte,  1846.  Abhandl. 
liber  Zahnschnierz. 


SUPPURATIVE    INFLAMMATION.  177 

menstrual  period.  In  most  cases,  the  inflammation  becomes 
suppurative,  i.  e.,  the  circumscribed  portion  of  the  surface  of 
the  pulp  presents  a  purulent  coating,  while  the  latter  often  has 
an  oedematous  appearance  or  is  covered  with  a  limpid  adhesive 
fluid.  If  there  is  no  obstruction  to  the  escape  of  the  pus,  when 
it  is  formed,  there  will  be  notable  remissions  in  the  piercing, 
dragging,  throbbing  pains ;  frequently,  indeed,  a  complete  in- 
termission, and  the  patient  is  only  reminded  of  the  affected 
pulp  by  pain  induced  by  special  exciting  causes.  The  acute 
form  then  passes  into  the  chronic. 

In  cases  where  the  pulp-cavity  is  not  yet  exposed  by  the 
carious  process,  and  the  pulp  is  shut  in  by  a  thin  layer  of 
dentine  merely,  external  influences  may  still  produce  their 
effects,  even  when  indirectly  applied.  In  such  cases,  that  con- 
dition is  presented,  which  dentists  term  odontalgia  nervosa  ex 
carte.  "Inflammation,"  says  Heider,  "  does  not  appear  to  be 
present,  for  the  accessions  of  intense  pain  occur  without  any 
warning,  and  even  with  great  intensity,  but  frequently,  however, 
intervals  occur,  during  which  there  is  entire  freedom  from  pain. 
Cold  applications,  which  diminish  the  pains  induced  by  inflam- 
mation, increase  them  in  these  cases. 

"  A  considerable  period  having  elapsed,"  he  continues,  "  after 
the  appearance  of  a  dark  spot  and  the  subsequent  destruction 
of  the  crown  of  the  tooth  at  the  part  corresponding  to  the  dis- 
coloration, the  tooth  becomes  sensitive  to  changes  of  tempera- 
ture ;  heat  and  cold  occasion  slight  and  transient  pains,  and 
hence  the  patient  is  careful  to  avoid  cold  and  hot  food  and 
drinks,  and  that  side  of  the  jaw,  upon  which  the  carious  tooth 
lies,  is  no  longer  employed  in  mastication,  because  the  pressure, 
even  of  the  particles  of  food  which  are  forced  into  the  carious 
cavities  in  masticating,  now  causes  quite  severe  pain.  After 
this  state  of  things  has  continued  a  longer  or  shorter  period,  a 
pain  suddenly  occurs  in  the  pulp,  usually  after  biting  something, 
of  such  severity  as  not  infrequently  to  bring  tears  into  the  eyes, 
and  if  it  continues  very  long  it  becomes  intolerable.  In  a  few 
minutes,  its  severity  diminishes  to  a  more  tolerable  degree,  but 
it  is  still  quite  severe  and  continues,  perhaps,  for  an  hour,  with 
exacerbations  and  intermissions,  and  finally  ceases  by  degrees, 

12 


178  INFLAMMATIONS. 

■when  an  interval,  usually  brief,  of  freedom  from  pain  ensues, 
but  soon  it  is  reproduced,  for  now  the  pulp-cavity  is  exposed, 
and  all  external  agencies  act  directly  upon  the  nerves.  The 
patient,  however,  is  not  always  free  from  severe  pains  until  the 
opening  of  the  pulp-cavity  ;  frequently,  after  the  occurrence  of 
transient  slight  pains,  a  mild  attack  is  succeeded  by  a  more 
acute  and  lasting  toothache,  with  intermissions  of  hours,  or  half 
a  day." 

Inflammation  of  pulps  which  have  been  denuded  by  penetra- 
ting caries,  may  be  circumscribed  or  general.  The  former  is 
found  in  those  cases  especially  where  the  perforation  of  the 
hard  tissues  by  the  carious  process  is  confined  within  narrow 
limits  ;  only  a  portion  of  the  body  of  the  pulp  is  implicated, 
perhaps  the  extremity  of  a  papilla  of  a  bicuspid  or  molar. 

The  most  prominent  indication  is  the  redness,  Avhich  is  due 
either  to  a  hyperremic  condition  of  the  bloodvessels,  or  to  the 
imbibition,  by  the  pulp-tissue,  of  the  coloring  matter  of  the 
blood,  which  is  deposited  from  the  red  blood- corpuscles.  Inter- 
mediate between  the  congestive  and  diffusive,  stands  the  hemor- 
rhagic redness  which  occurs  in  the  form  of  reddish  points  or 
spots.  The  borders  of  the  extravasation  generally  fade  away  im- 
perceptibly in  the  parenchyma  of  the  pulp.  In  cases  of  circum- 
scribed inflammation,  the  redness  is  limited  to  a  portion  of  the 
body  of  the  pulp,  and  diminishes  from  the  periphery  towards 
the  centre  ;  it  involves  one  or  another  root,  or  perhaps  only  the 
broader  portion.  The  intensity  of  the  redness  varies  between 
a  light  rose  red  and  a  deep  blood  red,  frequently  mixed  with 
gray,  which  preponderates  more  or  less.  When  the  inflamed 
pulp  is  accompanied  by  an  oedematous  enlargement,  it  acquires 
a  yellowish-red  appearance,  and,  attended  by  a  superficial  sup- 
puration, is  of  a  pale  greenish-yellow  color. 

The  increase  in  the  volume  of  the  pulp,  when  swollen  from 
the  effects  of  inflammation,  is  restricted  to  certain  limits  by  the 
resisting  dentinal  capsule,  within  which  it  lies,  and  the  view  has 
often  been  expressed,  that  the  resistance  of  the  capsule  is  the 
cause  of  the  intense  throbbing  and  lancinating  pains.  Though 
it  cannot  be  doubted  that  the  inflammatory  toothache  is  modified 
by  local  relations,  still,  on  the  other  hand,  we  think  it  should 


DENTAL    PULP.  179 

be  remembered  in  this  connection  that  intensive  neuralo-ias 
occur  under  the  most  varied  anatomical  relations.  The  swellino- 
of  the  pulp,  in  cases  of  circumscribed  inflammation,  is  limited 
to  one  or  another  portion,  but  a  circumscribed  swelling  can 
hardly  be  determined  in  many  cases,  and  is  best  recognized  in 
those  cases  where  the  inflammation  occurs  in  an  atrophic  pulp. 

With  reference  to  their  duration,  inflammations  are  divided 
commonly  into  acute  and  chronic,  both  of  which  present  various 
degrees  of  intensity.  The  more  acute  the  case,  so  much  the 
more  rapidly  is  the  parenchyma  destroyed,  and  the  more  chronic 
the  case,  the  more  moderate  are  the  symptoms  and  the  lono^er 
are  the  intervals  between  them.  In  the  former  case,  the  oro;an 
also  undergoes  a  relative  decrease  in  its  consistence,  and  may 
even  become  transformed  into  a  soft,  pultaceous  mass. 

The  suppurative  process  is  developed,  almost  always,  as  a  se- 
quence of  caries,  and  is  limited  to  the  superficial  layer  of  the 
body  of  the  pulp  or  of  the  root  portion  corresponding  to  the 
carious  locality  ;  the  suppuration  manifests  itself  in  the  form  of 
a  greenish-gray  or  greenish-yellow,  semi-fluid,  thready  covering, 
containing  pus-corpuscles  as  its  characteristic  morphological 
elements.  The  latter,  for  the  most  part,  have  undergone  fatty 
degeneration,  so  that  on  treating  them  with  acetic  acid,  the 
numerous  nuclei  are  obscured  by  the  presence  of  the  fat-gran- 
ules; indeed,  it  is  not  an  uncommon  occurrence  for  the  corpus- 
cles to  be  so  shrivelled  and  degenerated  that  they  are  no  longer 
recognizable.  The  fluid  basis  of  the  purulent  mass  is  rendered 
turbid  by  the  fat-globules  suspended  in  it,  which  latter,  also,  are 
presented  in  agglomerated  granular  masses.  By  adding  acetic 
acid,  the  mucus  is  precipitated  in  the  form  of  a  cloudy,  string;^ 
mass. 

Cases  are  met  with  frequently,  where  not  a  single  pus-cor- 
puscle, but  mere  agglomerations  of  shrivelled,  turbid  nuclei  im- 
bedded in  a  mass  resembling  coagulated  albumen,  are  to  be 
found,  in  the  superficial,  apparently  purulent,  substance. 

If  the  examination  is  extended  from  the  purulent,  infiltrated 
portion  of  the  pulp  to  the  deeper  layers,  it  will  readily  be  seen, 
in  acute  cases,  that  a  proliferation  of  the  cells  of  the  paren- 
chyma has  taken  place  and  may  be  traced  into  the  internal  por- 


180  INFLAMMATIONS. 

tions  even  far  do-\vn  into  the  root-pulp.  In  order  to  show  this, 
it  is  well  to  place  sections  of  such  pulps  in  paraffine,  glue,  or 
some  other  suitable  substance.  The  connective-tissue  cells  of 
the  pulp,  especially  in  young  individuals,  sometimes  present  a 
marked  proliferation.  For  instance,  binucleated,  roundish,  and 
spindle-shaped  cells,  are  frequently  observed,  as  the  principal 
forms,  and  these,  together  with  many  others  derived  from  them 
and  variously  shaped,  occur  in  such  large  numbers  that  they  are 
closely  compacted,  especially  in  the  vicinity  of  the  focus  of  in- 
flammation. Finally,  still  more  closely  packed,  agglutinated, 
elementary  organs  are  found,  consisting,  usually,  of  a  round 
nucleiform  body  surrounded  by  a  layer  of  protoplasnT  which  be- 
comes exceedingly  small. 

If  we  examine  the  bloodvessels,  structural  changes  may  be 
discovered  at  the  points  where  they  pass  into  the  focus  of  in- 
flammation, as  follows :  A  swollen  and  lax  condition  of  the 
fibrous  sheaths  of  the  small  arteries  and  veins ;  a  cloudiness  of 
the  sheaths,  occasioned  by  scattered  or  aggregated  fat-granules, 
or  by  larger  or  smaller  nuclei,  often  in  clusters,  which  not  infre- 
quently surround  the  entire  vessel,  whereby  the  characteristic 
elements  of  the  bloodvessel  are  lost,  and  it  can  only  be  recog- 
nized by  its  continuity.  Albrecht*  called  attention  to  the  no- 
table increase  in  the  volume  of  the  vessels  and  to  their  direc- 
tions, which,  instead  of  being  in  straight  lines,  are  exceedingly 
tortuous. t 


*  Krankheiten  der  Zahnpulpe,  1858. 

■j-  This  condition  is  observed  especially  in  connection  with  chronic  inflam- 
mation. The  prolonged  and  frequently  repeated,  augmented  pressure  of  the 
blood  occasions  a  diminution  of  the  elasticity  and  contractility  of  the  vas- 
cular walls;  coincident  with  the  proliferation  of  the  connective-tissue  ele- 
mentary organs,  the  vessel  loses  a  certain  amount  of  its  basis-tissue  which 
has  become  succulent;  after  expansion,  it  cannot  recover  its  former  length 
or  transverse  diameter,  but  becomes  longer  and  wider,  acquires  lateral 
flexions,  and  frequently  varicose  expansions  which,  when  they  lie  superfi- 
cially, easily  rupture  and  give  rise  to  the  above-mentioned  extravasations  of 
blood;  the  latter  subsequently  occasion  pigmental  degeneration  and  cloudi- 
ness. 

When  the  vessels  are  permanently  expanded,  disturbances  of  the  circula- 
tion are  more  liable  to  occur.     The   interchange  of  materials   in   proper 


DENTAL    PULP.  181 

The  bundles  of  nerve-tubes  in  the  vicinity  of  the  focus  of  in- 
flammation, also,  present  evidences  of  structural  changes.  The 
most  notable  indication  is  afforded  by  the  cloudiness  produced 
by  deposits  of  fat-granules  which,  partly  disseminated  and 
partly  aggregated,  are  deposited  between  the  nerve-tubes  and 
also  in  their  interior  (neuritis).  The  fat-granular  metamorpho- 
sis does  not  uniformly  involve  the  medullary  matter  even  of  one 
bundle  of  nerves,  that  is  to  say,  the  nerve-medulla  of  indi- 
vidual nerve-tubes  is  unaffected  by  fatty  degeneration.  Some- 
times, groups  of  oval  or  round  nuclei,  analogous  to  those  in  the 
bloodvessels,  are  met  with  in  the  fibrous  sheaths  of  the  nerves, 
and  indicate  a  proliferation  of  the  connective-tissue  elementary 
organs  (Atlas,  Fig.  80), 

Hence  it  may  be  concluded  that  the  occurrence  of  inflamma- 
tion in  the  nerve-bundles  of  the  pulp,  whether  it  results  in  a 
fatty  degeneration  of  the  nerve-medulla  or  in  a  cell  prolifera- 
tion of  the  interstitial  connective  tissue  of  the  bundles,  necessi- 
tates a  disturbance  of  the  conductibility  of  the  axis-cylinder, 
which  is  manifested  by  a  sensation  of  pain. 

The  protoplasm  of  the  dentinal  cells,  in  the  vicinity  of  the 
focus  of  inflammation,  is  rendered  cloudy  by  fat-granules ;  their 
cohesion  becomes  lax,  and  gradually  they  undergo  complete  dis- 
integration. 

In  cases  which  run  an  acute  course,  the  fatty  metamorphosis 
is  more  intensive  and  extensive  than  in  chronic  cases,  and,  co- 
incident with  this,  occurs  the  production  of  a  lax  condition  of 
the  pulp-tissue,  and  subsequently  dissolution  ensues,  so  that, 
finally,  there  remains  merely  a  discolored  membrane  adherent  to 
the  still  intact  wall  of  the  pulp-cavity  and  prolonged  into  the 
root-pulps  and  containing  the  shrivelled  remains  of  the  pulp. 

From  a  general  view  of  the  phenomena  attending  an  inflam- 
mation of  the  pulp,  it  appears  that  the  anomaly  in  the  inter- 


amounts,  can  no  longer  continue,  so  that  excretory  elements  are  retained, 
which  in  turn  occasion  still  further  impairment  of  function. 

In  consequence  of  the  stagnation  of  the  blood,  both  the  red  and  white 
corpuscles  become  necrotic;  the  former  yield  tlieir  coloring  matter  to  the 
fluid  in  which  they  are  immersed,  and  the  pulp  becomes  impregnated  with 
the  coloring  matter  of  the  blood. 


182  INFLAMMATIONS. 

change  of  material  is  manifested  by  an  augmented  supply  and 
diminished  witlidrawal  of  the  blood,  an  increased  transudation, 
and  an  accumulation  of  excretory  materials  :  further,  by  a  pro- 
liferation of  cells  which  form  the  stroma  of  the  pulp  and  the 
connective-tissue  investments  of  the  bloodvessels  and  nerves, 
and  by  an  abundant  development  of  pus-corpuscles  or  unusually 
large,  rapidly  shrivelling  nuclei,  which  prolifications,  together, 
induce  a  partial  or  complete  disorganization  of  the  parenchyma 
of  the  pulp. 

Acute  inflammation  of  the  pulp  frequently  results  in  a  gan- 
grenous destruction ;  usually  this  is  a  sequence  of  caries  of  the 
milk  and  permanent  teeth,  but  it  also  occurs  after  inflammation 
of  the  root-periosteum  and,  more  rarely,  is  developed  independ- 
ently. As  is  the  case  with  other  organs,  two  principal  forms  of 
gangrene  of  the  pulp  are  distinguished,  the  so-called  moht  and 
di-y.  The  former  is  characterized  by  a  dirty  deep  red,  brown- 
ish-red, reddish-gray  or  greenish-gray  discoloration  ;  a  diminu- 
tion of  the  consistence  to  that  of  a  thick,  pultaceous  mass, 
which  has  a  decided  penetrating,  fetid,  characteristic  gangren- 
ous odor.  Sometimes,  also,  the  pulp  becomes  transformed  into 
a  pulpy,  unctuous,  caseous,  disintegrated  mass,  with  a  nauseating 
odor. 

The  inflammatory  character  of  the  changes  in  the  tissues  may 
be  recognized,  unless  the  gangrene  has  made  too  great  progress, 
and,  for  this  purpose,  it  is  well  to  commence  the  investigation 
in  the  root  proper  and  to  continue  it  in  the  direction  of  the 
coronal  pulp.  The  sheaths  of  both  the  nerves  and  bloodvessels 
exhibit  the  above-mentioned  prolifications,  which  increase  pro- 
portionately as  the  gangrenous  focus  is  approached,  and  finally 
cover  the  whole  field  of  view.  The  evidences  of  fatty  degene- 
ration, also,  are  apparent  in  rapidly  increasing  progression. 
Here  and  there,  the  contents  of  the  nerve-tubes  are  disinte- 
grated. The  walls  of  the  bloodvessels  have  a  fat-granular  ap- 
pearance and  disintegrate  as  if  they  had  been  macerated;  the 
oblong  nuclei  of  their  organic  muscular  fibre  layers  are  scat- 
tered in  confusion.  Where  the  gangrenous  destruction  is  com- 
plete, a  dirty  yellow,  brownish-yellow  molecular  detritus  is 
found,  containing,  generally,  numerous  interposed,  long,  bow- 


DENTAL    PULP.  183 

shaped,  fatty  acid  crystals,  similar  to  those  found  in  the  sputa 
in  gangrene  of  the  lungs. 

In  the  so-called  dry  gangrene^  nothing  is  left  of  the  pulp  but 
a  blackish-brown,  brownish-red,  tinder-like,  shreddy  or  mem- 
branous, slightly  moist  mass,  which  only  partially  fills  the  pulp- 
cavity,  the  remaining  space  being  occupied  by  a  gaseous  fluid. 
The  principal  histological  elements  comprise  red  or  dark-brown, 
cylindrical  masses  (necrotic  blood)  inclosed  within  still  recog- 
nizable sheaths  (bloodvessels),  dirty  yellowish  or  brownish  ag- 
glomerations of  nuclei,  diminutive  pigment  grains,  crystals  of 
hgematoidin. 

In  most  cases  there  is  no  perforation  of  the  pulp-cavity,  though 
caries  has  preceded  the  gangrenous  condition  of  the  pulp.  In 
certain  cases  filling  the  tooth  may  be  the  predisposing  cause. 
The  primary  gangrene  appears  to  occur  particularly  in  teeth 
which  have  been  worn  away  by  attrition.  Besides  these  causes 
there  are  general,  obscure,  injurious  external  agencies  which 
also  promote  the  occurrence  of  gangrene  in  the  inflamed  pulp. 

When  the  red  coloring  matter  of  the  blood-corpuscles  transudes 
through  the  intact  vascular  walls,  or  escapes  from  the  corpuscles 
after  the  rupture  of  the  latter,  it  penetrates  the  dentine  and  im- 
parts a  reddish  color  to  the  teeth,*  which  generally  is  first 
noticed  upon  the  neck  of  the  tooth,  where  the  enamel  about  the 
dentine  terminates.  In  many  cases  the  redness,  which  is  a  pale 
rose  color,  is  limited  to  a  short  streak  upon  the  neck  in  the 
vicinity  of  the  root,  and  fades  away  towards  the  latter.  In 
other  cases  the  redness  is  more  intense,  and  spreads  towards 
the  extremities  of  the  roots,  being  more  marked,  generally, 
upon  one  side  than  upon  the  others.  The  coloring  may,  how- 
ever, be  most  decided  even  upon  a  portion  of  the  root. 

If  sections  are  made  to  show  the  amount  of  the  redness  pre- 
sented by  the  diff'erent  dentinal  layers,  now  and  then  instances 
are  met  with  where  the  inner  dentinal  zones,  towards  the  pulp- 
cavity  or  canal,  exhibit  very  slight  or  no  redness ;  next  to  this 
is  a  broader  or  narrower  middle  zone  of  a  brighter  tinge,  which 

*  M.  Heider  und  C.  Wedl  iiber  gerotbete  Zahne:  Deutsche  Viertelj.  f. 
Zahnheilk.     18G3. 


184:  INFLAMMATIONS. 

passes  into  the  weaker  color  of  the  outer  zone.  Sometimes  the 
inner  dentinal  zone  is  the  most  highly  colored. 

Tliin  sections  furnish  a  clear  idea  of  the  relative  amounts  of 
the  coloring  substance  in  the  different  dentinal  zones.  The 
dentinal  canals  are  filled  with  the  red  coloring  matter,  from 
their  origins  even  to  their  most  delicate  ramifications,  while  the 
basis-substance,  apparently,  is  not  colored  in  the  least.  The 
coloring  matter  presents  the  red  hue  of  the  blood  and  has  the 
appearance  of  a  homogeneous,  not  granular,  substance  filling 
the  canals.  It  is  evident  that  these  appearances  are  not  due  to 
the  phenomena  of  interference,  from  the  fact  that  sections  of 
normal  teeth  do  not  present  such  discolorations.  As  is  well 
known,  similar  colorings  may  be  produced  artificially,  e.  g.,  by 
means  of  carmine,  madder,  Prussian  blue,  blood-red,  &c.  It 
may  quite  readily  be  shown  by  experiment,  that  the  cement 
takes  up  none  of  the  coloring  matter.  If  the  latter  is  allowed 
to  act  from  the  pulp-cavity,  the  dentine  becomes  colored,  while 
this  does  not  ensue  if  the  root  of  the  tooth  is  surrounded  by  the 
coloring  matter,  a  fact  which  is  self-evident  if  the  root-canal  is 
closed.* 

The  varying  degrees  of  redness  presented  by  the  different 
dentinal  layers  may  be  referred  to  various  causative  conditions. 

*  We  immersed  dried  human  teeth,  the  crowns  of  which  were  broken  off, 
in  the  fresh  blood  of  a  rabbit  diluted  with  about  one-fourth  the  amount  of 
water,  upon  which  a  layer  of  oil  was  poured  in  order  to  prevent  evaporation. 
About  forty-eight  hours  afterwards,  the  dentinal  surfaces  were  exposed  and 
found  to  be  colored  more  or  less,  in  some  places  a  deep  red,  in  others  a  pale 
rose-red.  Sections  were  made,  which  showed  the  red  coloring  matter  de- 
posited within  the  dentinal  canals. 

In  order  to  solve  the  question,  whether  the  red  color  is  imparted  to  the 
dentine  in  a  direction  from  the  root-canal  or  from  the  cement  layer,  i.  e., 
from  the  inside  or  from  the  outside,  the  following  experiment  was  made.  A 
glass  tube,  six  inches  in  length  and  of  a  suitable  diameter,  was  fitted  to  an 
opening  into  the  pulp- cavity  of  a  lower  molar.  Eabbit's  blood  was  then  in- 
troduced into  the  tube  until  a  column  stood  above  the  pulp-cavity.  Further, 
some  teeth,  which  were  quite  intact,  were  placed  in  fresh  rabbit's  blood,  the 
openings  of  the  canals  at  the  extremities  of  the  roots  having  previously  been 
closed  with  sealing-wax.  The  result  of  the  two  experiments  was  conclusive. 
In  the  first  case  the  dentine  acquired  a  very  deep  red  color,  while  in  the 
latter  not  even  a  trace  of  discoloration  was  perceptible  in  several  sections  of 
the  teeth. 


DENTAL    PULP.  185 

It  is  to  be  remembered  tbat  the  middle  dentinal  zone  is  traversed 
by  more  numerous  ramifications  of  canals  than  the  inner  one. 
Our  perception  of  the  red  color  of  the  dentine  must  be  the  effect 
of  the  totality  of  the  reddened  canals  which  are  visible  to  a 
certain  depth  through  the  basis-substance.  If  the  latter  presents 
various  degrees  of  transparency,  then  the  red  coloring  will  also 
exhibit  corresponding  modifications.  The  reddish-yellow,  rose- 
red  or  gray-red,  or  reddish-gray  color  of  the  different  teeth, 
and  the  various  shades  in  the  several  dentinal  zones,  are  not 
due  to  casual  variations  in  the  coloring  matter  of  the  blood,  nor 
to  the  diminished  imbibition  of  the  latter  (one  can  satisfy  him- 
self, even  by  inspection,  of  the  uniform  coloring  of  the  tubules), 
but  within  certain  limits  are  dependent  upon  the  degree  of  trans- 
parency of  the  dentinal  basis-tissue.  With  caries  of  the  teeth, 
with  atrophy  of  the  dental  pulp,  the  dentine,  as  is  well  known, 
presents  a  dirty  white,  sometimes  yellowish-gray  color,  particu- 
larly towards  the  pulp-cavity  and  dental  canal,  in  localities,  in 
fact,  which  the  caries  has  not  attacked.  Accompanying  this 
condition  there  is  diminished  transparency  of  the  basis-sub- 
stance in  the  inner  dentinal  zone,  which  obstructs  the  perception 
of  the  coloring  matter  within  the  canals.  The  degree  of  redness 
depends,  also,  upon  the  disposition  of  the  reddened  canals.  If 
the  dentine  is  arranged  in  such  a  manner  that  only  small  por- 
tions of  the  canals  are  presented  to  view,  as  it  Avere  in  cross- 
section,  then  the  sensation  of  redness  produced  will  be  less 
marked  than  if  they  are  arranged  with  their  long  dimensions 
exposed  to  view,  so  that  a  larger  quantity  of  the  coloring  matter 
is  presented  to  the  retina. 

Since  the  dentinal  canals  inclose  the  ramifications  of  the  pro- 
cesses of  the  dentinal  cells,  it  appears  much  more  reasonable  to 
assume  a  process  of  imbibition  by  the  latter,  rather  than  capil- 
lary attraction. 

The  occurrence  of  reddened  teeth  is  confined  principally  to 
such  as  are  carious,  whose  pulps  present  a  deep-red  color  or  ex- 
travasations of  blood,  which  latter  correspond  in  location  to  the 
reddened  portions  of  the  dentine.  It  is,  also,  a  well-known  fact, 
that  when  incisors  are  treated  with  arsenic  or  caustic  paste  pre- 
vious to  the  operation  of  filling,  their  crowns  acquire  a  rose-red 


186  INFLAMMATIONS. 

color  in  the  course  of  a  few  weeks  or  a  month  after  the  operation 
of  filling.  This  discoloration  often  occurs  without  any  symptoms ; 
frequently,  however,  it  is  attended  by  symptoms  of  a  congestion, 
and  this  is  tiie  case  alwa^'s  with  teeth  whose  pulps  were  not  re- 
moved after  the  application  of  caustic  paste.*  Moreover,  red- 
colored  teeth  are  observed  also  as  a  post-mortem  appearance, 
after  cholera,  typhus,  and  death  by  suffocation.  Rose-red  teeth, 
with  a  variation  in  the  shading  upon  the  different  sides,  occur 
also  as  a  variety  of  formation. f 

Chronic  Inflammation  of  the  Pulp. — The  anatomical  appear- 
ances which  characterize  this  affection  comprise  a  more  limited 
extension  of  the  usually  pale  redness ;  diminished  succulence 
and  greater  consistence  of  the  tissues;  limited,  usually  not  very 
pronounced,  proliferation  of  the  connective-tissue  elementary 
organs  in  the  portions  denuded  by  the  carious  process ;  some- 
times superficial  suppuration;  in  many  cases,  an  atrophic  condi- 
tion of  the  pulp,  particularly  net-like  atrophy  in  which  extrava- 
sations of  blood  are  commonly  found  ;  a  secretion  of  a  serous 
fluid  with  an  offensive  odor  like  that  of  macerating  bone,  which 
however  does  not  properly  belong  to  the  fluid,  but  is  generated 
by  the  putrefaction  of  the  organic  constituents  of  the  dentine. 
The  paroxysms  of  pain  are  less  severe  and  less  prolonged  as  a 
rule.  Indeed  there  may  be  no  pain,  if  there  is  no  obstruction 
to  the  escape  of  the  usually  thin  serous  or  purulent  fluid  upon 
the  surface  of  the  exposed  portion  of  the  pulp.  Heat,  cold, 
chemical  or  mechanical  injuries  of  the  exposqd  portion,  always 
produce  an  uneasy  sensation  which  may  be  increased  to  severe 
pain. 

Chronio  Abscesses  in  the  Pidjj,  independent  of  Caries,  are 
very  rare.     The  case  illustrated  in  the  Atlas,  Fig.  51,  of  calci- 

*  [The  pulp  often  dies  as  the  result  of  the  use  of  arsenic  to  obtrude  sensitive 
dentine,  even  when  it  is  left  in  the  cavity  of  decay  but  a  short  time.  In 
these  cases  the  tooth  almost  always  becomes  reddened.  For  this  reason,  in 
this  country,  the  use  of  arsenic,  except  to  devitalize  the  pulp,  has  been  almost 
if  not  entirely  given  up.  Even  when  it  is  used  for  destroying  the  pulp,  un- 
less a  free  opening  is  made  through  the  walls  of  the  pulp-cavity  that  the 
fluids  may  And  exit,  intiltration  of  the  dentine  and  discoloration  follow. — 
T.  B.  II.] 

f  Heider  aus  der  Praxis:  Deutsche  Yiertelj.  f.  Z.,  1862. 


ABSCESSES  IN  THE  DENTINE.  187 

fication  of  the  root-pulps  of  a  grooved  molar  of  the  upper  jaw 
may,  perhaps,  be  regarded  as  a  case  in  point,  where  the  coronal 
pulp  contains,  besides  calcareous  deposits,  a  cyst-like,  spherical, 
quite  large  cavity,  with  smooth  walls,  which  is  separated  bv  a 
transverse  membranous  expansion  from  an  analogous  cleft-like 
cavity  extending  to  the  bottom  of  the  pulp-cavity.  There  is,  to 
be  sure,  no  actual  proof  that  the  cavity  in  question  is  that  of  an 
abscess ;  but  the  only  other  probability  is  that  it  is  the  cavity 
of  a  serous  cyst.  Still  more  rare  is  the  occurrence,  in  man.  of 
an  excavation  of  the  coronal  portion,  extending  hdo  the  dentine^ 
as  the  result  of  an  abscess.  Th.  Bell  *  reported  a  single  case 
which  came  under  his  observation.  A  physician  suffered,  for  a 
long  time,  from  severe  pain  in  the  right  side  of  the  upper  jaw, 
apparently  referable  to  the  second  molar  tooth  which,  however, 
presented  no*  external  evidences  of  disease.  After  some  time 
had  elapsed,  an  inflammation  of  the  root-membrane  ensued,  and 
the  tooth  became  loosened  a  little.  It  now  was  obvious  that 
this  tooth  was  the  source  of  the  pain,  which  finally  became  in- 
tense, and  so  it  was  extracted ;  as  its  exterior  presented  no  in- 
dications of  disease.  Bell  divided  it  with  a  saw,  at  the  upper 
part  of  the  crown,  and  found  a  completely  circumscribed  cavity 
in  the  dentine ;  the  surface  Avas  white  and  apparently  sound 
and  unbroken.  The  rest  of  the  tooth  did  not  present  the  least 
evidence  of  disease,  excepting  that  the  root-membrane,  which 
had  been  inflamed  for  a  long  time,  had  also  begun  to  suppurate. 
It  seems,  remarks  Bell,  that  the  inflammation  arose  primarily 
in  the  dentine,  from  some  local  cause ;  that  the  bloodvessels  of 
the  dentine  (of  the  pulp,  rather)  developed  suppuration,  and  ab- 
sorption ensued  in  consequence  of  pressure,  and,  in  this  way,  a 
cavity  was  produced  for  the  reception  of  the  pus.  We  shall 
frequently  have  occasion  to  refer,  in  the  following  pages,  to  the 
fact,  that  pus  produces  a  "usure,"  a  wearing  away  (usurire)  of 
the  dentine. 

In  the  teeth  of  large  mammals,  abscess  cavities  will  be  found 
quite  frequently  in  the  dentine^  if  one  only  takes  pains  to  search 
for  them. 

■^  Op.  cit. ,  p.  173. 


188  INFLAMMATIONS. 

The  tusks  of  elephants,  on  account  of  their  large  size  and 
great  projection,  are  exposed  to  manifold  mechanical  injuries, 
and  it  is,  also,  a  Avell-known  fact,  that  it  is  not  an  uncommon 
occurrence,  in  working  ivory,  to  find  bullets  imbedded  in  the 
tooth,  which  then  presents  pathological  changes,  that  render  it 
unsuitable  for  the  purposes  of  the  ivory  turner.  The  attention 
of  Goethe*  was  attracted  long  since  to  the  changes  in  ivory 
which  are  produced  by  bullets  imbedded  within  it ;  he  speaks  of 
cavities  in  the  diseased  limits,  which  are  partially  lined  by  a 
delicate  membrane. 

We  are  indebted  to  J.  Tomesf  for  the  very  thorough  descrip- 
tion of  cavities  of  this  nature  in  two  tusks.  The  dentinal  sub- 
stance in  each  of  the  two  tusks  presented  a  newly-formed  cavity, 
having  no  connection  with  the  pulp-cavity,  nor  indeed  any  out- 
let. One  of  them  was  quite  empty,  dry,  and  contained  a  small 
quantity  of  a  desiccated  membranous  mass,  or  a  fluid,  which 
was  apparent  in  the  most  dependent  portion  of  the  cavity,  where 
it  had  become  inspissated.  In  the  other  case,  the  cavity  was 
broader,  also  without  any  outlet,  encompassed  by  dentinal  sub- 
stance and  lined  with  a  dried  membrane ;  here  and  there,  small 
spinous  processes  of  dentinal  substance  projected  from  the  walls 
of  the  cavity.  The  dentine  encompassing  the  cavity  had  a 
veined  appearance  like  mai'ble,  occasioned  by  the  different  di- 
rections assumed  by  the  dentinal  tubules,  and  also  was  traversed 
by  numerous  canals  of  the  character  of  bloodvessels  and  visible 
to  the  naked  eye.  The  lining  membrane  of  the  cavity  was  de- 
tached and  macerated  in  water,  and  proved  to  be  a  fibro-cellular 
tissue.  According  to  these  statements.  Tomes  appears  to  have 
taken  no  notice  of  the  new  formation  of  osseous  substance 
around  the  abscess-cavity. | 

Albrecht  holds  the  view,  for  which  there  are  grounds,  that 
the  vessels  in  the  dentine  of  the  second  case  can  have  been 
formed  only  by  the  prolongation  of  the  vessels  of  the  pulp.  He 
assumes,  then,  that  vaso-dentine  does  not  occur  in  the  tusk  of 
the  elephant.     According  to  R.  Owen,§  small  bloodvessels  ex- 

*  Osteologische  Mittheilungen,  1798. 
f  Albrecht,  Krankli.  d.  Zahnpulpe,  p.  23. 
X  Compare  New-formations. 
I  Odontography. 


ABSCESSES    IN    THE    DENTINE. 


189 


tend  forward  in  the  axis  of  the  tusk  as  far  as  its  apex,  and  the 
bloodvessels  may,  also,  penetrate,  even  to  the  dentine,  from  those 
of  the  root-membrane,  if  the  abscess-cavity  be  located  near  the 
outer  surface. 

By  the  kindness  of  Prof,  von  Schroff,  I  had  the  opportunity 
of  examining  segments  of  elephants'  tusks  which  were  labelled 
ulcers.  They  contain  extensive  abscess-cavities  in  the  dentine, 
apparently  entirely  shut  in,  of  the  size  of  a  pigeon's,  a  hen's, 
even  of  a  goose's  egg  and,  here  and  there,  present  irregular 
parietal  sinuations.  The  cavities  are  lined  by  a  desiccated, 
dirty-yellow,  brownish-yellow,  dark-brown  and  black  mass.  The 
portions  adjacent  to  the  cavities  have  a  mottled  look,  and  con- 
sist, principally,  of  vascularized  osseous  tissue,  Avhich  forms  a 
layer  of  varying  thickness  encompassing  the  abscess-cavities, 
dips  more  or  less  deeply  into  the  dentine,  and  presents  in  sec- 
tions various  sinuations  and  islands  (Fig.  75).     If  we  trace  the 

Fig.  75.* 


process   of  resorption  of  the   ivory   from    the   side  of  the   en- 
croaching osseous  tissue,  it  will  be  observed  that  both  the  main 

*  Fig.  75  shows  a  section  from  the  tusk  of  an  elephant,  containing  a  large 
abscess-cavity  which  upon  one  side  approaches  to  within  six  millimetres  of 
the  periphery.  It  presents  various  cup-like  excavations  and  is  lined  with 
an  adherent,  dried,  dirty  brownish-yellow  mass.  That  portion  of  the  wall 
which  incloses  the  inferior  segment  of  the  cavity,  is  transformed  into  an 
ununiform  tissue  (a)  (osseous  tissue)  to  a  depth  of  five  to  ten  millimetres, 
the  line  of  demarcation  between  it  and  the  normal  dentine  being  sharply 
defined.  This  tissue  has  a  wavy  outline,  a  spotted  and  striped  appearance, 
and  its  consistence  is  less  than  that  of  normal  dentine.  Two-thirds  natural 
size. 


190  INFLAMxMATIONS. 

trunks  and  the  lateral  branches  of  the  dentinal  canals  present 
numerous  varicous  expansions,  Avhile  portions  of  them  are  trans- 
formed into  jagged,  elongated  cavities,  or  give  place  to  a  glob- 
ular, transparent  substance.  In  other  portions,  large,  multi- 
radiating  bone-corpuscles  have  encroached  upon  the  dentine,  or 
vascular  canals  have  become  surrounded  by  concentric  layers  of 
osseous  substance.  From  the  wall  of  another  abscess-cavity, 
conical  processes,  one-half  to  one  millimetre  broad  at  the  base 
and  two  to  four  millimetres  in  length,  project  into  it,  and 
are  composed  partly  of  a  minutely  lobulated  (kleindrusig), 
globular  mass,  together  with  bone-corpuscles,  and  partly  of  den- 
tinal canals,  anastomosing  without  irregularity  in  various  direc- 
tions and,  here  and  there,  forming  tufts  which  extend  in  the 
direction  of  the  axis  of  the  conical  process. 

A  condition,  also,  is  presented  which  essentially  bears  a  close 
analogy  to  that  observed  by  Tomes.  The  new  hard  formations 
upon  the  wall  of  the  abscess  (abscedirenden  Wand)  form  a  re- 
parative tissue  which  tends  to  replace  the  substance  lost  by  the 
suppurative  process,  and  probably  their  development  would  have 
gone  on  still  farther,  so  that  they  would  have  diminished  the 
area  of  the  cavity,  had  they  been  supplied  with  fresh  formative 
material  by  the  bloodvessels.  As  I  had  only  sections  at  my 
disposal,  I  was  unable  to  make  special  investigations  with  refer- 
ence to  the  origin  of  the  bloodvessels,  which  are  the  necessary 
antecedents  to  the  production  of  both  the  new  dental  and  osse- 
ous tissues  and,  also,  of  the  suppurative  process.  In  all  proba- 
bility, the  newly-formed  bloodvessels  Avere  outgrowths  from 
those  of  the  pulp.  The  elucidation  of  this  question  remains 
for  future  special  investigation. 

The  chronic  inflammation  of  the  periphery  of  the  abscess 
(Abscesshaut),  in  these  cases,  led  to  the  production  of  solid 
tissues  (osseous  and  dentinal),  both  of  which  must  have  been 
developed  from  cells.  But  even  if  we  are  willing  to  admit  that 
the  bloodvessels  of  the  new-formed  substances  are  derived  from 
other  pre-existing  ones,  still  the  appearance  of  the  new  osseous 
and  dentinal  substance  in  the  wall  of  the  abscess-cavity  con- 
tinues to  be  an  extraordinary  phenomenon,  and  the  assumption 
in  relation  to  their  appearance,  that  the  cell-life  of  the  con- 


DENTAL    PULP.  191 

ncctive-tissue  parietes  of  the  abscess  is  exalted  to  a  diflferentia- 
tion,  as  in  embryonic  life,  is  open  for  discussion,  since,  indeed, 
we  cannot  by  any  means  presuppose  that  the  germs  of  the 
formative  cells  are  transported  to  the  part  with  the  blood. 

As  a  general  rule,  as  has  been  shown  above  at  considerable 
length,  injlammalion  of  the  pulp  imparts  a  reddish  color  to  the 
dentine.  Albrecht*  observed  dark-colored  portions  of  dentine 
in  localities  corresponding  to  small  defects  which  were  visible  in 
the  lining  of  the  wall  of  the  pulp-cavity  and  extended  as  far 
as  the  enamel  layer.  It  was  observable,  however,  that  the  dark 
color  Avas  confined  principally  to  the  dentinal  canals,  and  was 
much  less  perceptible  in  the  intervening  substance.  The  affected 
tooth,  he  says,  undergoes  a  change  of  color,  under  these  cir- 
cumstances, the  dentinal  substance  becomes  gray-black  and  as- 
sumes the  condition  of  a  gray,  pulverous,  structureless  mass, 
which  is  perceptible  through  the  enamel  layer,  the  latter  re- 
maining intact  for  a  much  longer  period.  Apparently,  he  ob- 
served no  circumscribed  defect  in  the  dentine  upon  the  inside, 
and,  indeed,  this  is  found  only  very  rarely  in  conjunction  with 
a  discoloration  of  the  tooth.  Dr.  Steinberger  informed  me, 
that  he  could  call  to  mind  only  a  single  instance  which  occurred 
in  Heider's  practice,  where  the  dentine  had  become  softened  by 
the  extension  of  gangrene  from  the  pulp-cavity.  In  this  case, 
Heider  exposed  and  filled  the  cavity,  and  succeeded  in  preserv- 
ing the  tooth.  Cases  of  this  kind  may  possibly  have  given  rise 
to  the  supposition  of  the  occurrence  of  caries  interna  (compare 
Anomalies  of  the  Secretions). 

Chronic  inflammations  in  the  pulp  lead  to  various  forms  of 
atrophy,  among  which,  chronic  fatty  degenerations  and  calcifi- 
cations are  to  be  mentioned  especially.  The  new-formations, 
which  are  consequent  upon  an  irritation  of  the  elementary 
organs  of  the  pulp,  include  those  of  dentine,  osseous  substance 
and  connective-tissue  cells  (sarcomatous  proliferations). f  The 
return  to  an  entirely  normal  condition  is  very  exceptional,  and 
whenever  there  seems  to  be  a  probability  of  such  an  occurrence, 
frequent  relapses  will  undeceive  one.     In  fact  the  pathological 

*  Op.  c'it.,  p.  21.  f   Vide  New-formations. 


192  INFLAMMATIONS. 

germs  of  the  cells  persist,  and  the  latter  are  called  into  renewed 
activity  under  the  influence  of  trifling  causes.  Chronically  in- 
flamed pulps  may,  also,  become  gangrenous  and  transformed, 
partially  or  entirely,  into  a  fetid,  pultaceous  mass. 

An  important  affection,  which  frequently  occurs  as  a  sequel 
of  inflammation  of  the  pulp,  is  that  of  the  periosteum  of  the  root, 
a  fact  easily  explained,  when  the  relations  of  the  bloodvessels 
and  nerves  are  taken  into  consideration.  This  membrane  be- 
comes swollen,  abscesses  are  formed,  generally  at  the  extremities 
of  the  roots,  and  the  pus  finds  an  exit  into  the  substance  of  the 
gum  or  into  other  regions,  to  be  mentioned  farther  on. 

Gums. — According  to  the  locality  and  symptoms,  there  is  dis- 
tinguished a  superficial  inflammation  of  the  gums,  which  is  con- 
fined to  the  outer  mucous-membrane  layer,  and  a  general  paren- 
chymatous inflammation  which  is  not  limited  to  the  outer,  but 
attacks,  as  well,  the  deeper  layers.  The  character  of  these  in- 
flammations is  controlled  by  the  genetic  conditions  which  are 
the  foundation  of  the  processes,  and  its  determination  presents 
manifold  difficulties.  The  mere  form,  independent  of  all  other 
clinical  evidence,  aff"ords  insufficient  grounds  for  an  opinion  as 
to  its  character.  Individual  peculiarities  modify  the  general 
eff"ect  of  the  disease,  and  the  combinations  of  diff'erent  processes 
produce  a  variability  in  the  phenomena.  In  many  cases  it  is 
possible  merely  to  make  distinctions  with  reference  to  the  course 
of  the  disease,  that  it  is  acute  or  chronic.  Every  inflammation 
of  the  gums  may  give  rise  to  a  superficial  or  deep  destruction  of 
the  substance  of  the  gum  and,  likewise,  may  cause  a  destruction 
of  neighboring  tissues. 

In  catarrhal  inflammation  of  the  gum,  the  latter  assumes  a 
rose-red  color  which  is  most  apparent  upon  the  free  edges;  sub- 
sequently, white  spots  appear  and  disappear,  which  are  produced 
by  the  exfoliation  of  the  epithelium.  The  gum  feels  uniformly, 
though  not  notably,  swollen,  smooth,  and  hot.  The  patient 
complains  of  annoying  sensations  of  itching,  tickling,  and  burn- 
ing, which  are  diminished  temporarily  by  grinding  the  teeth. 
A  livid  gray,  mucilaginous,  frequently  puriform  secretion  col- 
lects in  the  pockets  formed  by  the  gum,  and  oozes  out,  when 
the  finger  is  pressed  along  its  border. 


GUMS.  193 

This  inflammation  occurs  most,  frequently  upon  the  labial 
surface  of  the  incisors  and  canines  of  the  lower  jaw,  and  more 
rarely  upon  the  same  surface  of  the  corresponding  upper  teeth. 
In  the  latter  case,  the  covering  of  the  hard  palate  of  the  affected 
side  becomes  involved.  Still  more  rarely  are  the  gums  of  the 
bicuspids,  and  almost  never  are  those  of  the  molars  attacked. 
The  affection  either  is  limited  to  the  gums  of  a  few  teeth  merely, 
or  invades  those  of  all  the  incisors  and  canines  of  one  jaw,  less 
frequently  of  both  jaws,  and  never  those  of  all  the  teeth  of 
either  jaw. 

The  inflammation  ma^^  continue  months  and  even  years,  par- 
ticularly upon  the  lower  jaw  where  the  secreted  fluid  accumulates 
Avithin  the  pockets  formed  by  the  gums.  In  cases  of  unusually 
long  duration,  it  spreads  to  the  periosteum  of  the  root,  gives 
rise  to  resorption  of  the  margin  of  the  alveolus  and  loosening  of 
the  tooth  in  its  socket. 

The  more  acute  forms,  in  most  cases,  are  due  apparently  to 
the  same  causes  which  generally  give  rise  to  catarrhal  conditions, 
to  excessive  variations  in  temperature,  damp  and  cold  weather, 
&c.  Another  very  frequent  cause,  particularly  of  inflammation 
of  the  gums  of  the  incisors  and  canines,  is  the  prolonged,  con- 
tinually-repeated mechanical  injury^  to  which  these  teeth  are 
subjected  in  closing  the  jaws,  when  several  molars  and  bicuspids 
are  wanting.  With  the  latter  condition  the  incisors  and  canines 
are  pressed  together  more  firmly  in  chewing  and  experience 
slight  movements  in  their  sockets,  whereby  the  gums  and  root- 
membrane  become  irritated  and  swollen.  As  the  mechanical 
injury  continues,  a  process  of  resorption  of  the  margins  of  the 
alveoli,  also,  is  induced,  the  tooth  becomes  loose  and  finally 
falls  out. 

An  accumulation  of  tartar  with  its  rough  outer  surface,  also, 
produces  a  mechanical  irritation  of  the  margins  of  the  gums 
and  gives  rise  to  a  chronic  catarrh,  while  the  secretion  of  the 
latter,  on  the  other  hand,  occasions  an  increased  formation  of 
tartar.  Each  process,  consequently,  promotes  the  development 
of  the  other. 

In  cases  where  caries  has  destroyed  the  greater  part  or  the 
whole  of  the  coronal  portion  of  the  tooth,  the  sharp  edges  of  the 

13 


19-i  INFLAMMATIONS. 

cup- shaped  carious  cavity  become  a  sourne  of  irritation  of  the 
margins  of  the  gums  ;  the  putrid  products  of  decomposition, 
which  result  from  the  carious  process,  also  have  a  similar  effect. 
If  the  neck  of  the  tooth,  also,  or  a  portion  of  the  root  is  destroyed 
by  caries,  the  gum  loses  its  support,  becomes  detached,  inverted, 
and  acts  as  an  additional  constant  source  of  irritation. 

With  tobacco  chewers  and  those  who  smoke  filthy  pipes  and 
strong  cigars,  especially  if  the}^  do  not  pay  proper  regard  to 
cleanliness,  the  tobacco  juice  becomes  an  important  source  of 
irritation. 

Catarrhal  inflammation  is  observed,  also,  as  an  accompaniment 
of  catarrh  of  the  intestinal  tract. 

The  character  of  the  catarrhal  secretion  is  essentially  modified 
by  the  constitutional  peculiarity  of  the  individual.  In  tubercu- 
lous people,  generally  a  very  abundant,  frequently  puriform, 
secretion  is  observed,  and  the  affection  is  usually  very  obstinate, 
wdiile  with  individuals  who  are  healthy  in  other  respects,  it  dis- 
appears directly  on  the  removal  of  the  irritating  cause.  Super- 
ficial ulceration  of  the  gums  is  a  not  uncommon  sequel  of  a 
neglected  or  obstinate  catarrhal  inflammation ;  such  ulcers  are 
flattened  and  covered,  at  the  base,  with  a  firmly-adherent  gray 
mass ;  they  heal  finally  without  leaving  a  perceptible  breach  of 
substance. 

If  the  old  epithelium,  even  in  the  minor  catarrhal  affections, 
is  not  removed,  but,  remaining  adherent,  becomes  mixed  with 
the  debris  of  food,  and  if,  in  addition,  there  is  also  a  gastric 
catarrh,  the  cells  become  disintegrated,  their  contents  thickened, 
and  between  the  layers  are  found  the  familiar  fermentation 
fungi  (mucor),  which  are  very  abundant  in  mucus,  under  the 
favorable  conditions  afforded  especially  by  individuals  present- 
ing evidences  of  impaired  nutrition,  e.  </.,  in  the  marasmus  of 
infants  or  the  emaciating  diseases  engendered  by  unhealthy 
surroundings  (thrush).  The  mucous  membrane  which  has  now 
acquired  a  deep  red  color  is  beset  with  soft,  white  nodules,  or  is 
covered  with  membraniform  layers  which  may  be  stripped  off; 
the  latter  spread  to  the  adjacent  portion  of  the  oral  mucous 
membrane,  but  rarely  are  attended  with  an  ulceration.  In  cases 
of  this  description  the  catarrhal  affection  is  not  to  be  referred  to 


GUMS.  195 

the  fungi  (Oirlium  albicans)  as  a  cause,  although,  to  be  sure, 
there  is  no  doubt  but  that  the  latter,  in  consequence  of  their 
enormous  productivity,  become  a  source  of  irritation  in  the  in- 
flamed mucous  membrane  and,  consequently,  tend  to  continue 
and  add  to  the  catarrhal  process  already  developed.  Bacteria 
are  found  associated  with  copious  mucous  or  puriform,  fetid 
secretion  of  the  gums  ;  these  will  receive  special  consideration 
in  connection  with  the  subject  of  Anomalies  of  Secretion. 

In  the  vesicular,  herpetic [?)  injlammation  of  the  gum,  vesicles 
are  formed  which  give  rise  to  itching  and  burning  sensations. 
The  vesicles  collapse  or  rupture  and  there  remains  a  superficial 
erosion  which  heals  without  cicatrization.  Usually  it  extends 
to  regions  adjacent  to  the  gum. 

Inflammatory  affections  of  the  gum  are  developed  in  the 
course  of  the  acute  exanthemata,  such  as  variola,  scarlet  fever, 
measles,  and  are  accompanied  by  indications  peculiar  to  these 
diseases.  With  persons  aff"ected  with  syphilis,  Avho  have  not 
been  under  the  influence  of  mercury  for  a  long  time,  a  very 
marked  softening  of  the  gum  is  said  to  occur,  according  to  G. 
Delestre.* 

In  mercurial  salivation,  according  to  the  statements  of  Corfe 
which  J.  Tomes  confirms,  the  action  is  indicated  primarily  by 
the  gums,  indeed  several  hours  prior  to  the  occurrence  of  the 
flow  of  saliva;  according  to  J.  Tomes  the  indications  are  as 
follows  :f  "The  mucous  membrane  of  the  gums,  where  it  is 
firmly  adherent  to  the  tissues  beneath,  assumes  an  opaque,  white 
color,  contrasting  strongly  with  the  non-adherent  portion,  which 
preserves  its  natural  hue  or  becomes  more  red.  The  free  edge 
of  the  gum  is  movable,  but  that  portion  which  lies  upon  the 
alveolar  margin  is  firmly  attached  to  the  periosteum,  and  as  the 
margins  of  the  alveoli  have  a  festooned  outline,  so  the  whitened 
mucous  membrane  presents  corresponding  undulations.  Again, 
the  mucous  membrane  preserves  its  natural  color,  where  it  is 
reflected  from  the  gum  to  the  cheek.  The  diminished  tenacity 
of  the  epithelial  cells  contributes  to  the  production  of  the  Avhite- 
ness  of  the  gum.     When  the  epithelium  exfoliates,  the  reddened 

*  Du  ramollisement  des  gencives.     Paris,  1861. 
f  Dental  Phys.  and  Surg.,  p.  299. 


196  INFLAMMATIONS. 

papilhirj  portion   becomes   exposed,  and   the  gum   acquires  a 
mottled  appearance." 

Lead  may  give  rise  to  a  partial  bluish  coloring  of  the  gums. 
Dr.  Brinton*  observed  this  condition,  in  a  case  of  lead  colic, 
upon  the  edge  of  the  gum  corresponding  to  the  incisors  of  an 
entirely  sound  set  of  teeth.  •  He  regarded  the  blue  edge  as  due 
to  a  sulphuret  of  lead,  produced  by  a  deoxidation  of  a  salt  of 
lead.  Probably  the  saliva  contained  lead,  and  the  deoxidation 
■was  occasioned  by  the  sulphureous  matter  contained  in  the 
atmosphere. 

Croupous  inflammation  of  the  gum  is  an  affection  of  consider- 
able importance,  both  on  account  of  its  sudden  occurrence  and, 
also,  because  it  is  liable  to  assume  a  diphtheritic  character. 

Steinbergerf  describes  the  occurrence  of  the  malady  as  fol- 
lows :  "  In  the  first  stage,  the  edge  of  the  gum  is  covered  with 
a  whitish,  gray,  structureless,  membraniform  exudation,  scarcely 
half  a  line  in  thickness,  which  may  be  detached  in  flakes.  The 
mucous  membrane,  deprived  of  its  epithelium,  is  slightly  swollen, 
tender  to  the  touch,  and  bleeds  easily.  Generally  the  exudation 
first  appears  upon  the  outer  side,  that  is  upon  the  margin  of  the 
gum  of  the  lower  jaw  which  faces  towards  the  lips  and  cheeks, 
and  frequently  within  the  limits  of  the  lower  incisors,  whence  it 
spreads  gradually  over  the  whole  anterior,  and  also  the  posterior 
margin  Avhich  faces  the  tongue.  It  is  a  rare  occurrence  for  it 
to  attack  the  edges  of  the  gums  of  the  upper  and  lower  jaw  at 
the  same  time. 

"The  exudation  takes  place  very  rapidly,  often  in  a  few  hours, 
not  infrequently  during  the  night,  and  is  accompanied  by  a  very 
painful  sensation  which  the  patient  describes  as  a  dragging 
pain,  and  this  is  increased  if  the  patient  remains  in  warm 
localities,  or  in  bed.  There  is  only  slight  febrile  movement ; 
frequently  it  is  scarcely  perceptible.  The  cervical  glands  of  the 
afl"ected  side  are  swollen. 

"  The  exudation  degenerates  very  rapidly  into  an  offensive, 
sanious  mass,  so  that  the  affection  becomes  manifest  from  the 

*  Qiiar.  Jour,  of  Dental  Science,  1857. 

f  Croupose  Entziindung  des  Zahnfleischrandes  und  ihre  Folgen  :  deutsche 
Vierteljahresschr.  f.  Zuhnheilk.,  1861. 


GUMS.  197 

patient's  breath,  even  at  a  distance  of  several  paces.  The  de- 
composed matter  dips  down,  especially  in  the  lower  jaw,  between 
the  gums  and  the  tooth,  towards  the  root-membrane,  which  be- 
comes inflamed  and  finally  is  destroyed  by  the  corroding  sanious 
matter.  The  teeth  are  loosened  and  fall  out,  or  may  readily  be 
removed.  Subsequently  the  bone,  from  the  imbibition  of  the 
sanious  matter,  becomes  necrosed,  without,  however,  at  least  in 
most  cases,  the  occurrence  of  any  swelling,  showing  that  the 
necrosis  originates  from  the  alveolar  cells  and  not  from  the  peri- 
osteum of  the  jaw. 

"In  the  upper  jaw,  as  a  rule,  the  destructive  process  is  not 
so  extensive,  in  consequence  of  the  ready  escape  of  the  purulent 
fluid. 

"  If  the  inflammatory  process  leads  to  the  death  of  the  gum 
and  the  facial  wall  of  the  alveolar  process  (in  other  words,  if  a 
diphtheritic  slough  is  formed),  the  necrosed  portions  of  the  bone 
exfoliate,  and  in  children  the  dental  germs  are  exposed. 

"  Children  are  more  frequently  the  subjects  of  the  latter 
afi"ection  than  adults,  and  those  children  particularly  who  have 
been  reduced  by  scarlet  fever,  measles,  and  typhus.  Still  it 
also  attacks  healthy,  robust  persons. 

"  The  predisposing  cause,  in  most  cases,  is  exposure  in  a  cold, 
damp  dwelling,  or  to  a  cold,  damp  draught  of  air  or  excessive 
exposure  to  moisture  and  cold  in  travelling  and  hunting.  The 
disease  acquires  a  contagious  character  in  hospitals  for  children. 

"  The  duration  of  the  disease  depends  upon  its  intensity  and 
extent,  the  general  health  of  the  patient,  and  external  circum- 
stances. The  more  mild  cases  terminate  in  eight  to  fourteen 
da3^s,  and  the  more  severe  ones  often  last  several  months." 

Since  the  croupous  inflammation,  which  has  been  described, 
often  spreads  to  a  considerable  distance  in  the  mucous  membrane 
of  the  oral  cavity,  consequently  attacks  portions  beyond  its 
original  seat,  the  gums,  it  is  called  by  the  general  term  stomatitis, 
and  from  the  fact  that  it  is  associated  with  ulceration,  Taupin* 
called  it  stomatitis  ulcero-membranacea,  and  maintains  that  it  is 
entirely  distinct  from  diphtheritis.  Distinguished  writers,  on 
the  other  hand,  admit  a  transition  from  croup  into  diphtheritis. 

*  Barthez  and  Riliiet.     Diseases  of  Children. 


198  INFLAMMATIONS. 

Phlegmonous  infiammation  of  the  gums  involves  both  the 
corium  and  the  submucous  connective  tissue,  and  is  attended  by 
considerable  swelling  and  redness. 

Under  this  head  may  be  classed  the  series  of  cases  which 
Pye  Smith*  collected,  and  to  which  he  gave  the  name  stomatitis 
hemorrhagica.  The  accession  is  sudden  and  without  any  febrile 
movement ;  the  oral  mucous  membrane,  especially  that  of  the 
gums,  becomes  swollen  without  any  participation  on  the  part  of 
the  neighboring  mucous  membrane,  the  fauces,  nasal  mucous 
membrane,  and  larynx.  Ulceration  occurs  in  small,  shallow, 
yellowish  spots,  or  is  in  the  form  of  a  large,  phagedenic  ulcer. 
Actual  necrosis  of  the  osseous  substance  may  ensue.  The  in- 
tervening mucous  membrane  is  always  tumid,  spongy,  very  sen- 
sitive, and  easily  bleeds.  Recovery  is  very  slow.  The  disease 
was  observed  in  well-nourished,  otherwise  healthy  persons,  who 
presented  no  indications  of  scorbutus  or  syphilis. 

Siqypurative  (abscedirend)  injlammation  generally  issues  in  a 
circumscribed  formation  of  pus,  an  abscess  (pa7'uUs),  which 
latter  usually  opens  externally,  but  sometimes  undergoes  re- 
sorption. Its  course  depends  upon  the  causes  to  which  it  owes 
its  origin.  If  it  is  produced  by  a  mechanical  cause,  such  as 
compression,  contusion  or  laceration,  it  heals  directly,  with  the 
occurrence  of  suppuration.  If  the  suppuration  results  from  an 
inflammation  of  the  root-membrane,  in  connection  Avith  caries, 
it  disappears  immediately  with  the  removal  of  the  inflammation 
of  the  root-membrane,  and  if  the  latter  assumes  a  chronic  char- 
acter, the  inflammatory  irritation  becomes  extended  to  the  gums 
and  a  fistulous  track  is  formed,  which  opens  externally  upon 
the  surface  of  the  gum,  where  it  presents  indurated  edges,  while 
the  other  extremity  communicates  with  the  suppurating  root- 
membrane,  or  maxillary  periosteum,  or  with  an  abscess  within 
the  bone  (Atlas,  Fig.  118).  The  fistula  evidently  cannot  be 
expected  to  heal  until  after  the  removal  of  the  causes  which 
give  rise  to  the  irritation. 

Acute  or  inflammatory  oedema  of  the  gums  is  accompanied  by 
a  considerable,   pale   tumefaction   and  great  tension,   and  fre- 

*  Virchow's  Archiv.,  1870 ;  zur  Gingivitis. 


DISEASES    OCCASIONED    BY    THE    FIRST    DENTITION.         199 

quently  is  developed  very  rapidly  by  the  action  of  mechanical 
or  chemical  irritants. 

Gangrene  of  the  mouth  {noma)  also  attacks  the  gums,  which 
become  decomposed  into  a  gangrenous  slough  or  sanies  in  which 
float  the  necrotic  fringes.  As  is  well  known,  if  the  gangrene 
attacks  the  deeper  parts,  the  maxillary  periosteum  and  the  root- 
membrane  are  destroyed,  and  the  patients  (who  usually  are 
weak,  badly-nourished  children,  living  in  dark,  low,  cold,  and 
moist  rooms),  lose  the  incisors,  canines,  or  bicuspids;  portions 
of  the  bones  become  denuded  and  necrosed  and,  sometimes,  the 
greater  portion  of  the  upper  or  lower  jaw  is  lost.* 

Diseases  occasioned  by  the  First  Dentition. — It  is  well 
known  that,  wuth  children  born  of  healthy  parents  and  whose 
external  surroundings  in  life  are  not  detrimental,  teething  is 
unattended  by  morbid  phenomena  which  latter,  however,  make 
their  appearance  in  children  of  unhealthy  parents,  or  in  those 
who  are  subject  to  the  influences  of  obnoxious  external  agencies. 
While  abnormal  dentition  may,  perhaps,  have  been  over-esti- 
mated by  the  physicians  of  former  days,  it  is,  on  the  other  hand, 
sometimes  too  little  regarded,  indeed,  even  disregarded  entirely 
by  those  of  recent  times,  as  a  cause  of  affections  of  the  nervous 
system,  intestinal  tract,  respiratory  organs,  <&c.  Up  to  the 
present  time,  as  far  as  I  know,  no  one  has  yet  made  the  en- 
deavor, wdiich  it  is  hoped  wuU  be  made,  to  establish  first  of  all 
an  anatomical  basis  for  abnormal  dentition,  by  its  pathologico- 
anatomical  study.  Physicians,  as  a  general  rule,  are  not  fa- 
miliar enough  with  the  process  of  dentition,  and  dentists  are 
not  disposed,  nor  do  they  have  the  opportunity  of  prosecuting 
that  study  to  any  great  extent. 

Fox,  and  Avith  him  a  large  number  of  English  dentists,  having 
in  mind  the  morbid  processes  consequent  upon  difficult  denti- 
tion, attached  great  importance  to  lancing  the  gums.  "  If  the 
nurse,"  he  says,  "be  attentive,  she  will  notice  that  the  child 
does  not  take  the  nipple  with  the  same  degree  of  force  as  usual, 
or  holds  it  but  a  short  time,  and  soon  lets  it  go  ;  the  gums  feel 
hot  and  are  redder  than  usual;  the  cheeks  appear  flushed,  the 

*  Barthez  and  Killiet,  vol.  ii. 


200  INFLAMMATIONS. 

eyes  look  heavy,  and  the  chihl  is  uneasy.  AVhen  these  symp- 
toms appear,  the  mouth  should  be  examined  and  if  there  be  any 
fulness  of  the  gums,  or  they  have  the  appearance  of  inflamma- 
tion, they  should  be  lanced  at  that  part.  The  order  in  -svhich 
the  teeth  appear  should  always  be  kept  in  mind,  and  then  there 
will  be  little  probability  of  mistake,  as  to  the  spot  where  the 
cause  of  irritation  is  seated.  To  delicate  children  there  is 
often  danger  attending  the  cutting  of  the  canines  and  first 
molars,  since  these  teeth  advance  in  growth  almost  at  the  same 
time,  so  that  there  are  eight  teeth  making  pressure  upon  the 
gums  at  the  same  time." 

According  to  Trousseau,*  the  swelling  of  the  gums  is  not  an 
arching  produced  by  the  tooth  beneath,  but  is  due  rather  to  the 
inflammation,  and  he  adduces  in  support  of  his  assertion,  the 
fact  that  this  turgescence  occurs  and  disappears  again,  without 
the  emergence  of  the  tooth  through  the  gum  ;  direct  experi- 
ment also  confirms  this  view,  for  if  a  needle  be  inserted  into  the 
swollen  gum,  it  is  found  to  be  three  to  four  millimetres  in  thick- 
ness, from  the  surface  down  to  the  tooth.  He  found  that  the 
inflammation  of  the  gum  Avas  always  much  more  marked  around 
the  upper  incisors,  than  around  the  lower  ones.  Trousseau 
does  not  coincide  with  the  older  physicians,  in  the  opinion  that 
teething  is  the  cause  of  most  of  the  diseases  of  infancy,  and 
states  that  the  local  condition  plays  merely  an  accessory  part. 
The  painful  swelling  of  the  gum  and  the  toothache  give  rise  to 
various  symptoms,  particularly  to  flushing  of  the  cheeks,  saliva- 
tion, fever,  agitation,  and  likewise  to  a  few  nervous  symptoms. 
He  doubts,  however,  that  the  diarrhoea  is  the  secondary  result 
of  the  pain,  and  remarks  that  diseases  which  occur  during  the 
process  of  dentition,  such  as  broncho-pneumonia,  pneumonia, 
and  enteritis,  are  always  more  severe  and  dangerous,  and  further 
that  among  all  the  methods  of  local  treatment,  lancing  the 
gum  is  by  far  most  in  favor,  but  it  surely  merits  no  recommen- 
dation. 

Inflammatory  swellings  of  the  gums,  attending  the  eruption 
of  the  milk  teeth,  may  assume  a  very  alarming  character.     "In 

*  Barthez  and  Eilliet,  vol.  i. 


DISEASES    OCCASIONED    BY    THE    SECOND    DENTITION.     201 

some,  fortunately  rare  cases,"  says  0.  Weber,*  "  the"  inflamma- 
tion may  lead  to  a  periostitis  of  the  jaw,  particularly  of  the 
upper  jaw,  which,  if  it  be  not  ti-eated  very  carefully,  may  give 
rise  to  gangrenous  destruction  similar  to  noma.  In  such  cases, 
the  cheek  becomes  swollen,  then  oedematous,  and  later  acquires 
a  phlegmonous  condition.  The  eyelids  assume  a  puffy  appear- 
ance, the  whole  face  becomes  swollen  and  tense,  and  a  careless 
physician  might  regard  the  case  as  one  of  erysipelas.  If  the 
condition  of  the  teeth  is  not  recognized,  and  exit  is  not  given  to 
the  pus  already  formed  beneath  the  periosteum,  by  free  inci- 
sions, the  cheek  may  become  gangi'enous  and  the  jaw  necrosed 
and  destroyed.  It  is  unnecessary  to  state  that  this  condition  is 
attended  with  high  fever.  In  one  case  of  this  kind  in  which  gan- 
grene was  imminent,  I  preserved  the  life  and  the  face  of  a  child 
only  by  general  incisions  at  various  parts,  since  the  suppuration 
had  advanced  already  to  the  region  beneath  the  orbits  and 
beyond  the  zygoma."  This  all  goes  to  show  that  inflammations 
of  the  gums  during  the  eruption  of  the  milk  teeth  are  to  be 
watched  with  the  greatest  care,  and  we  must  not  assent  to  the 
nihilistic  doctrine  (Nihilismus),  in  respect  of  the  influence  of 
difficult  teething  upon  the  infantile  organism  (compare  Neu- 
roses). 

Diseases  occasioned  by  the  Second  Dentition. — The 
eruption  of  the  wisdom  teeth  not  infrequently  gives  rise  to  mor- 
bid phenomena  which,  as  Hunter  has  observed,  are  more  local- 
ized, while  in  the  first  dentition  they  are  apt  to  be  more  general 
than  local.  The  diseasesf  comprise,  1,  neuralgic  affections  of 
the  facial  and  temporal  nerves,  occasionally  of  an  intermittent 
type;  2,  a  very  obstinate  cough  like  hooping-cough;  the  par- 
oxysms are  shorter  and  the  prolonged  inspiration  is  wanting  ; 
3,  very  obstinate  attacks  of  dysenteric  diarrhoea,  Avhich  continue 
five,  six,  even  seven  months,  while  the  general  condition  and 
appetite  are  not  disturbed. 

The  difficult  eruption,  of  the  wisdom  teeth  is  due,  in  most 
cases,  to  their  faulty  position,  together  with  insuflicient  length 

*  Handbuch  der  allg.  und  spec.  Chirurgie  redig.  v.  Pitha  und  Billroth, 
Bd.  iii,  p.  234. 

f  Barthez  and  Riiliet,  vol.  i. 


202 


INFLAMMATIONS. 


of  the  jaws,  and  especially  of  the  lower  jaw,  or  to  some  affection 
of  the  adjacent  tooth.     For  example,  Fig.  76  represents  an  ex 


Fig.  76.= 


tensively  'carious,  lower  second  molar,  on  the  left  side,  the 
alveolus  of  which,  together  with  the  surrounding  portion  of  the 
jaw,  was  infiltrated  with  sanious  matter.  The  pathological  pro- 
cess commenced  with  an  inflammation  of  the  periosteum  of  the 
root  which  was  followed  by  periostitis  and  the  formation  of  a 
minutely  porous  osteophyte,  and  necrosis  of  the  contiguous  por- 
tions of  the  jaw.  The  eruption  of  the  wisdom  tooth,  which  was 
inclined  somewhat  anteriorly,  had  commenced,  and  the  anterior 
seo;ment  of  the  alveolus  was  involved  in  the  sanious  ulceration. 
If,  in  this  case,  the  second  carious  molar  had  been  extracted  at 
the  proper  time,  the  consecutive  inflammatory  processes  wouhl 
not  have  been  so  extensive. 

A  notable  disturbance  is  presented  at  the  time  of  the  eruption 
of  the  wisdom  teeth,  if  ulceration  of  the  alveolar  processes  and 


*  Fig.  76  shows  a  circumscribed  necrosis  upon  the  lingual  wall  of  the  left 
lower  maxillary  arch,  corresponding  to  the  carious  second  molar,  and  also 
a  finely  porous  osteophj-te-formation  upon  the  adjacent  portion  of  the  maxil- 
lary wall.  The  wisdom  tooth  («)  has  just  made  its  appearance.  The  dis- 
colored, necrosed  portion  is  sharplj^  defined,  and  adjacent  to  it  is  deposited  a 
thin  finely-porous  osteophyte,  which  spreads  *anteriorh'  upon  the  lingual 
surface  as  far  as  (6),  and  posteriorly  nearly  to  the  articular  condyle.  A  fistu- 
lous opening  was  formed  upon  the  facial  wall  of  the  jaw  beneath  the  posterior 
root  of  the  second  molar.  The  porous  osteophyte  extends  anteriorly  upon 
this  surface  as  far  as  the  mental  foramen  and  posteriorly  to  the  condyloid 
process.     Natural  size. 


DISEASES    OCCASIONED    BY    THE    SECOND    DENTITION.     203 

subsequent  dislocation  of  the  teeth  have  ensued  (Fig.  77).     In 
this  case,  it  is  very  probable  that  a  retarded  eruption  of  the 

Fig.  77.* 


*  Fig.  77  shows  the  teeth,  on  the  left  side  of  the  upper  and  lower  jaws, 
bent  forwards,  in  consequence  of  a  partial  destruction  of  the  alveolar  pro- 
cesses, probably  the  result  of  a  diphtheritic  periostitis,  which  was  caused  by 
the  eruption  of  the  deeply-imbedded  wisdom  teeth  on  the  left  side.  (For 
the  specimen  from  the  Anatom.  Museum,  the  author  is  indebted  to  Dr. 
Friedlowski.)  The  two  central  incisors  and  the  left  lateral  of  the  upper 
jaw  are  bent  upwards  into  a  nearly  horizontal  position;  the  left  upper 
canine  and  the  two  bicuspids  are  inclined  to  a  less  degree  ;  the  first  molar, 
on  the  left  side,  occupies  its  normal  position  ;  the  second  is  displaced  towards 
the  tongue  and  is  covered  with  a  deposit  of  tartar  (a) ;  the  emergent  wisdom 
tooth  (/;)  has  a  marked  forwai'd  inclination  and  is  located  to  the  outside  of 
and  behind  the  second  molar.  In  the  lower  jaw,  the  coronal  boi'ders  of  the 
central  incisors  are  separated  by  an  interval  of  eighteen  millimetres  from 
each  other,  the  result  of  an  ulcerative  inflammation  of  the  alveolar  process  ; 
notwithstanding  this  notable  gap,  no  tooth  has  fallen  out;  the  incisors, 
canine,  and  two  bicuspids  of  the  left  lower  jaw,  are  inclined  towards  the 
lips,  and  the  second  bicuspid  (r)  is  displaced  to  the  front  of  the  buccal  surface 
of  the  first  molar  ;  the  second  molar  is  bent  towards  the  tongue  ;  the  wisdom 
tooth  has  a  horizontal  position  with  its  masticating  surface  directed  ob- 
liquely towards  the  tongue.  The  bone  around  the  latter  tooth,  like  that 
upon  the  maxillary  tuberosity  of  the  upper  jaw,  is  destroyed,  and  to  such  an 
extent,  that  the  roots  are  exposed  for  the  most  part.  The  wisdom  teeth, 
upon  the  right  side,  occupy  normal  positions  within  the  dental  ranges ;  the 


204  INFLAMMATIONS. 

wisdom  teeth,  on  the  left  side,  gave  rise  to  an  inflammation  of 
the  gums,  which  extended  upon  the  facial  surface  of  the  latter, 
along  the  upper  and  under  dental  arches,  involved  the  periosteum 
of  the  facial  walls  of  the  alveolar  processes  and  destroyed  these 
walls  and,  also,  the  anterior  walls  of  the  dental  sockets.  The 
osseous  substance  surrounding  the  wisdom  teeth  was  necrosed, 
a  result  of  the  periostitis.  The  lingual  walls  of  the  alveolar 
processes  Avere  not,  but,  as  may  be  seen,  the  margin  of  the  in- 
cisive fossa  on  the  frontal  process  of  the  upper  jaw,  and  the 
anterior  borders  of  the  ascending  coronoid  process  of  the  lower 
jaw,  were  involved  in  the  ulcerative  process.  The  teeth,  de- 
prived of  the  support  afforded  by  the  facial  walls  of  the  alveolar 
processes  and  jaws,  became  very  much  inclined.  This  case 
shows  Avhat  may  be  the  results  of  neglect  and  ignorance.  If 
the  wisdom  teeth  are  deeply  imbedded  in  an  oblique  position, 
they  may,  during  their  eruption,  give  rise  to  fistulous  abscesses.* 
A  case  came  under  the  observation  of  Heider,  in  which  resorp- 
tion of  the  single  root  with  exposure  of  the  pulp-cavity  of  the 
second  molar  occurred  in  connection  with  a  very  marked  forward 
inclination  of  an  erupted  wisdom  tooth.  He  also  saw  another 
case,  which  presented  resorption  of  the  root  of  a  lateral,  perma- 
nent incisor,  in  connection  with  the  retarded  eruption  of  an  ab- 
normally located  canine. f  Wisdom  teeth  of  the  lower  jaw,  which 
lie  in  a  horizontal  or  oblique  position,  may  also  be  the  foundation 
of  the  occurrence  of  tumors  in  the  osseous  substance.^ 

Root-Membrane. — Inflammation  of  the  periosteum  of  the 
root  is  of  especial  importance,  not  merely  on  account  of  its  fre- 
quent occurrence,  but  also  from  its  tendency  to  invade  the 
neighboring  tissues ;  its  importance,  however,  was  not  fully 
estimated  until  within  the  last  decades  of  this  century.  John 
Hunter  considered  it  to  be  an  inflammation  of  the  socket  of  the 


teeth  of  this  side,  in  part,  are  notably  affected  by  caries.  There  remains, 
finally,  to  be  mentioned,  an  accumuhvtion  of  tartar  upon  the  lingual  surfaces 
of  the  dental  crowns  on  the  leftside.     Two-thirds  natural  size. 

*  Durand.  Ill  effects  produced  by  the  eruption  of  a  wisdom  tooth,  in 
I'art  Dentaire,  Paris,  1860. 

t  Deutsche  Viertelj.  f.  Z.,  18G2. 

X  Dental  Eegister,  1869.     Affections  of  the  Jaw.     Waterman. 


ROOT-MEMBRANE.  205 

tooth,  and  described  it  as  "gum  boil,"  which  is  still  its  popular 
name.  Lefoulon  (1841)  distinguished  it  as  periodontitis ;  Lin- 
derer  (1842),  as  an  inflammation  of  the  external  dental  mem- 
brane. We  are  indebted  to  Albrecht*  for  a  monograph  upon 
the  subject. 

With  reference  to  the  extent,  there  is  distinguished  a  localized, 
limited  to  one  tooth  or  perhaps  to  one  root  of  a  tooth  with  mul- 
tiple roots,  and  general  inflammation  which  spreads  over  a  whole 
row  of  teeth  of  the  upper  or  lower  jaw,  as  with  phosphornecrosis, 
for  instance,  or  hydrargyriasis,  and  diphtheritic  inflammation  of 
the  gums.  It  is  further  separable  into  a  primary  and  secondary, 
an  acute  and  chronic  form. 

Bearing  in  mind  the  anatomical  relations  of  the  root-mem- 
brane, its  connection  with  the  vessels  and  nerves  Avhich  enter 
the  pulp,  with  the  alveolus  and  gums,  and  with  the  periosteum 
and  bony  substance  of  the  jaAV,  the  phenomena  that  accompany 
the  inflammation  are  readily  accounted  for.  Although  these 
make  their  appearance  in  regular  succession,  it  is  customary, 
for  the  sake  of  greater  clearness,  to  divide  them  into  stages  as 
follows  : 

1.  Inflammatory  thickening,  with  hyperremia  and  commencing 
proliferation  of  the  elementary  organs  of  the  connective  tissue, 
which  takes  place  both  in  the  parenchyma  of  the  root-membrane 
and  also  in  the  fibrous  sheaths  of  the  bloodvessels  and  nerves. 
Groups  of  nuclei,  presenting  the  familiar  forms  which  result 
from  their  division  and  inclosed  within  a  protoplasm,  become 
apparent  and  occasion  faint,  cloudy  spots. 

2.  In  the  second  stage,  the  cloudiness  increases  and  pervades 
the  entire  thickened  root-membrane  Avhich  acquires  a  gray-red- 
dish appearance.  The  groups  of  proliferating  elements  assume 
larger  proportions;  the  nuclei  and  also  the  investing  protoplasm 
acquire  a  molecular  cloudiness ;  here  and  there,  they  present  a 
shrivelled  appearance,  vessels  and  nerves  become  unrecognizable, 
the  basis-substance,  the  intercellular  tissue  is  displaced,  for  the 
most  part,  by  the  products  of  the  proliferation,  and  supplanted 
by  fat-granules.  In  many  cases,  the  inflammatory  process  ter- 
minates with  this  proliferation. 

*  Die  Krankheiten  der  Wurzelhaut  der  Zahne,  1860. 


206  INFLAMMATIONS. 

3.  In  the  tliird  stage  suppuration  takes  place,  and  the  same 
series  of  pathological  phenomena  ensue,  as  have  been  described 
above  in  connection  "with  the  suppurating  pulp  (Atlas,  Fig.  80). 

In  ver}'-  acute  cases  the  proliferation  of  the  elementar}^  organs 
takes  place  very  rapidly,  and  their  degeneration  ensues  iinme- 
d\ate]y. 

Tiie  clinical  history  of  the  first  stage,  in  the  acute  form,  as 
given  by  Heider,  is  as  follows:  Sensitiveness  of  the  root  in- 
volved, which  at  first  is  not  continuous  and  is  characterized  as 
a  dull,  undefined  sensation  of  oppression  in  the  tooth.  After 
this  has  continued  some  time  (for  days  or  hours),  uninterrupted 
pains  occur  in  the  tooth,  which  are  notably  increased  by  contact 
with  anything,  especially  by  attempts  to  chew,  by  simply 
closing  the  mouth,  or  by  percussing  the  tooth,  particularly  in 
the  direction  of  the  root.  The  pains  are  also  intensified  by  the 
local  application  of  warmth  and  by  general  heating  of  the  body, 
by  active  movements,  the  horizontal  position,  and  spirituous 
drinks.  There  is  now  developed  a  distinct  sensation,  as  if  the 
tooth  was  increasino;  in  length  and  becoming  loose.  The  former 
is  subjective  merely,  the  latter,  evidently,  is  objective  also,  since 
the  aff"ected  tooth  can  be  moved  with  the  application  of  but  slight 
force.  These  same  symptoms  are  also  presented,  to  a  less  de- 
gree, by  the  two  teeth  adjacent  to  the  one  originally  affected. 

Then  occur  the  phenomena  presented  by  the  gums,  which,  at 
the  corresponding  portions,  become  more  red,  more  hot  to  the 
touch,  swollen  and  sensitive  to  pressure  with  the  finger,  particu- 
larly in  the  vicinity  of  the  apex  of  the  root. 

The  secretion  of  saliva  is  augmented,  and  increased  heat  and 
redness  is  observed  upon  the  affected  side.  With  irritable  per- 
sons, there  is  general  indisposition,  a  coated  tongue,  loss  of  ap- 
petite, and  sometimes  febrile  movement. 

These  symptoms  oftentimes  continue  only  a  few  hours,  and 
again  may  last  for  days,  and  then  all  at  once  become  more 
marked.  The  pains  become  more  intense,  almost  intolerable ; 
the  patient  can  no  longer  endure  contact  of  anything  with  the 
tooth,  not  even  of  the  tongue  ;  the  mouth  cannot  be  closed  ;  the 
tooth  apparently  increases  in  length,  since  it  is  raised  per- 
ceptibly above  the  level  of  the  dental  range,  especially  when 


ROOT -MEMBRANE.  207 

the  tooth  has  several  roots  ;  there  is  a  corresponding  increase 
in  its  mobility;  the  contact  of  anything  hot  cannot  be  borne, 
and  the  patient  is  unable  to  take  solid,  cooked  food,  or  even 
tepid  liquids  ;  cold  local  applications  produce  a  temporary  relief, 
but  the  pain  returns  in  a  more  severe  form.  At  the  same  time 
the  swelling  of  the  gums  increases  considerably  and  also  extends 
to  the  mucous  membrane  of  the  cheek,  and  to  the  integument 
of  the  face,  which  becomes  oedematous  as  the  disease  progresses. 
When  the  front  teeth  are  affected,  the  lips  become  swollen  and 
produce  a  marked  disfigurement ;  their  mucous  membrane  be- 
comes elevated  into  bulUie,  and  the  ala  of  the  nose  on  the  cor- 
responding side  is  swollen.  When  the  bicuspids  and  molars  of 
the  upper  jaw  are  attacked,  the  loAver  eyelid  becomes  oedema- 
tous, and  this  condition  may  increase  so  as  to  produce  a  complete 
closure  of  the  eye.  With  the  affection  of  the  teeth  of  the  lower 
jaw,  the  oedema  spreads  downwards  upon  the  neck,  principally, 
and  may,  especially  when  the  wisdom  teeth  are  involved,  extend 
to  the  mucous  membrane  of  the  soft  palate,  and,  if  not  checked, 
oedema  of  the  glottis  may  ensue.  The  neighboring  glands,  par- 
otid and  sublingual,  likewise,  are  swollen,  as  might  be  expected. 
Accompanying  these  symptoms,  the  oral  cavit}'  becomes  quite 
hot,  the  tongue  thickly  coated  ;  an  extremely  offensive,  purulent 
odor  is  emitted  from  the  mouth,  and  the  mucous  secretion  be- 
comes very  adhesive.  At  this  stage,  there  is  an  accession  of 
general  symptoms,  including  more  or  less  notable  febrile  move- 
ment, general  indisposition,  headache,  thirst,  and  even  delirium 
with  very  irritable,  plethoric  individuals. 

With  the  latter  symptoms,  suppuration  occurs,  while  the  pain 
loses  its  acute  character  and  assumes  a  more  dull  and  beating 
form.  The  portion  of  the  gum  adjacent  to  the  tooth,  which 
was  primarily  affected,  swells  considerably  and  projects  in  the 
form  of  a  fold.  The  tumor,  which  now  has  attained  its  greatest 
dimensions,  becomes  soft  and  fluctuating  and  in  time  presents 
a  yellowish  spot,  where  the  pus  becomes  perceptible  and  makes 
its  exit,  if  the  tumor  is  left  to  itself.  As  soon  as  the  pus  is 
evacuated,  there  is  a  very  rapid  diminution  in  the  intensity  of 
all  the  symptoms ;  the  oedema  disappears  in  a  few  hours,  and 
after  the  lapse  of  about  twenty-four  hours,  the  swelling  is  re- 


208  INFLAMMATIONS. 

stricted  to  the  locality  of  the  tooth  originally  affected.  If  the 
suppuration  diminishes  considerably  during  the  succeeding  days, 
then  the  tooth  resumes  its  original  position  and  firmness,  and 
becomes  serviceable  again  ;  on  the  other  hand,  circumstances 
may  give  rise  to  additional  suppuration,  the  looseness  of  the 
tooth  and  the  discoloration  increase,  and  finally  its  death  ensues 
and  it  is  lost.  The  average  duration  of  the  acute  process,  such 
as  has  been  described,  is  seven  to  eight  days. 

The  suppuration  is  reduced,  in  the  course  of  time,  to  a  mini- 
mum, Avhere  it  is  kept  up  for  a  considerable  period,  until  the 
small  opening  in  the  membrane  becomes  closed,  the  location  of 
■which  is  then  denoted  by  a  small  nodule.  Relapses  are  occa- 
sioned by  slight  causes,  among  which  may  be  mentioned  expos- 
ure of  the  feet  to  cold,  in  particular,  overheating,  stimulating 
drinks,  &;c.  A  small  vesicle  is  formed  at  the  original  seat  of 
disease  -which  becomes  filled  with  pus,  and  is  ruptured  by  the 
movements  in  mastication  and  evacuated.  Usually  the  opening 
closes  after  this,  and  in  a  few  days  again  a  small  pustule  is 
formed  at  the  same  place  which  runs  the  same  course  as  the 
first.  Sometimes  the  latter  process  is  repeated  for  months, 
without  troubling  the  patient,  and  is  due  to  a  chronic  inflam- 
mation of  the  root-membrane. 

The  clinical  history  of  chronic  inflammation  comprises  the 
following  most  prominent  symptoms:  An  uneasy,  sometimes 
painful  sensation,  referred  to  the  root,  which  is  increased  by 
pressure  upon  the  tooth  and  by  chewing.  The  gum  of  the 
aff'ected  tooth  is  reddened,  and  pressure  in  the  vicinity  of  the 
apex  of  the  root  gives  rise  to  pain.  The  tooth  sometimes  ap- 
pears to  be  longer  than  usual  and  loose,  which,  however,  is 
merely  an  imaginary  sensation  on  the  part  of  the  patient.  At 
first,  these  symptoms  are  altogether  of  such  an  ill-defined  nature, 
that  they  easily  escape  the  notice  of  less  observant  patients, 
Avho  are  not  made  aware  of  the  affection  until,  in  the  course  of 
time,  either  severe  pains  are  felt  at  the  apex  of  the  root,  or  the 
edge  of  the  gum  becomes  tumid,  and  a  yellowish  mucus  oozes 
out  between  the  latter  and  the  neck  of  the  tooth.  In  conse- 
quence of  detrimental  agencies,  the  latter  process  progresses, 
and  intermittent,  inflammatory  pains  are  developed,  especially 


ROOT-MEMBRANE.  209 

■when  the  inflammation  is  located  at  the  apex  of  the  root.  The 
redness  of  the  gum  increases,  its  margins  become  swollen,  the 
outer  wall  of  the  alveolus  is  very  sensitive  to  pressure,  the  tooth 
cannot  be  employed  in  chewing,  becomes  loose  and,  apparently, 
increased  in  length.  Frequent  remissions  occur,  but  the  same 
process  is  repeated  after  longer  or  shorter  intervals,  and  ends 
with  the  loss  of  the  tooth.  The  process  continues,  throughout, 
a  local  one  and  the  general  system  is  not  disturbed.  This  con- 
dition of  things  is  observed  most  frequently  in  well-nourished, 
vigorous,  middle-aged  persons. 

While,  in  the  acute  form,  the  proliferation  of  the  cellular 
elements  of  the  connective  tissue  is  arrested  in  the  embryonic 
stage  of  the  latter  and  a  partial  degeneration  is  induced  by  the 
luxuriance  of  the  cell-production,  in  the  chronic  inflammation 
a  higher  grade  of  organization  is  attained,  but  under  favorable 
conditions,  the  chronic  may  be  changed  into  the  acute  form. 

The  periosteum  of  the  root  presents  a  gradual  increase  in 
thickness  towards  the  apex  of  the  root,  its  tissue  is  compact,  its 
outer  surface  not  infrequently  like  felt  and,  sometimes,  highly 
vascular  (Atlas,  Fig.  122).  Besides  the  roundish  or  ovoid  con- 
nective-tissue cells,  rows  of  spindle-shaped,  elongated  cells,  also, 
are  met  with ;  later  in  the  progress  of  the  aff'ection,  Avavy, 
curled  bundles  of  connective  tissue  appear  in  the  basis-sub- 
stance, between  which  rows  of  roundish  cells  are  imbedded.  In 
such  localities  the  nerves  and  vessels  undergo  a  perceptible 
wasting  away,  while  the  larger  bloodvessels  are  expanded. 
The  proliferating  connective  tissue  undergoes  a  partial  involu- 
tion [retrograde  metamorphosis]  which  is  manifested  by  the 
appearance  of  fat-granules,  partly  within  the  protoplasm  of 
the  cells  themselves,  and  partly  in  the  intermediate  substance ; 
but,  nevertheless,  germs  of  proliferation  may  persist,  wdiich  will 
be  excited  to  renewed  activity  with  the  occurrence  of  an  irrita- 
tion. If  the  degenerative  process  goes  on  to  the  transformation 
of  the  tissue  into  a  minutely  molecular  mass  (detritus),  which 
frequently  occurs  without  any  perceptible  suppuration,  it  always 
displays  itself  first  on  the  outer  zone  of  the  root-membrane 
(Atlas,  Fig.  123).  It  is  self-evident,  that  the  connection  of  the 
root-membrane  with  the  alveolus,  at  the  latter  locality,  becomes 

14 


210  INFLAMMATIONS. 

destrojccl,  and  tlie  tooth  is  loosened  in  its  socket  by  this  pro- 
cess. 

Inflammation  of  the  closed  extremity  of  the  periosteum  of 
the  root,  with  suppuration  in  the  inner  layers  of  tissue,  some- 
times occurs,  giving  rise  to  the  formation  of  a  spherical  sac  of 
pus,  which  may  attain  the  size  of  a  small  pea.  As  is  well 
known,  it  is  not  an  uncommon  occurrence,  Avhen  the  affected 
tooth  is  extracted,  to  find  the  sac  unbroken  and  attached  like  a 
berry  to  the  apex  of  the  root.  According  to  Hulme,  sacs  of 
this  kind  very  rarely  result  from  an  acute,  but  almost  invariably 
from  a  chronic  inflammation. 

The  fibrous  envelope  of  the  pus  sac  (in  subacute  cases  ?) 
forms  a  thin,  transparent  wall,  which  is  traversed  by  a  network 
of  bloodvessels  and  incloses  a  distinctly  fluctuating,  purulent 
mass,  mixed  with  more  or  less  blood.  In  chronic  cases,  the  en- 
velope is  thick,  less  smooth  upon  its  outer  surface,  and  fluctua- 
tion is  less  distinct.  In  the  latter  cases,  it  is  composed  of  three 
separate  layers;  a,  an  external,  thicker,  more  resistant  layer 
in  which  cells  of  an  oblong  shape,  imbedded  in  a  fibrous  stroma, 
predominate;  b,  a  middle,  less  firm,  more  succulent  layer, 
containing,  principally,  rounded,  nucleated  cells  which  are  in- 
serted into  a  felted  mass  of  filaments,  in  parallel  rows  or  in 
irregular  clusters ;  c,  an  internal  layer,  a  sort  of  granulation 
tissue,  with  the  pus  adherent  to  it.  The  thicker  the  wall  of  the 
sac,  the  less  recognizable  is  the  central  focus  of  suppuration, 
and  in  that  case,  cross-sections  present  a  network  of  branching 
trabeculne  of  connective  tissue,  inclosing  groups  of  stellate  con- 
nective-tissue cells.  In  old  purulent  deposits,  a  disintegrated 
mass  containing  fat-granules  and  cholesterin,  is  accumulated  at 
the  centre  of  the  sac. 

Chronic  inflammation  also  gives  rise  to  hypertrophy  and 
tumors  of  the  root-membrane  and,  sometimes,  leads  to  hyper- 
trophy or  exostosis  of  the  cement. 

That  portion  of  the  root-membrane,  which  is  in  relation  with 
the  submucous  connective  tissue  of  the  gums,  appears  to  be  at- 
tacked secondarily,  in  most  cases,  in  consequence  of  the  exten- 
sion of  the  disease  either  from  the  inflamed  closed  extremity  of 
the  root-membrane  or  from  the  inflamed  irums.     In  these  cases. 


ROOT -MEMBRANE.  211 

the  gum  becomes  detached  from  the  neck  of  the  tooth,  and  pres- 
sure upon  the  alveolus  forces  out  a  puriform  fluid.  This  condi- 
tion, which  has  been  described  as  lyyorrlioea  alveolaris,  particu- 
larly by  French  writers,*  results,  without  notable  pain,  in  the 
loss  of  the  affected  tooth.  It  also  attacks  whole  sets  of  teeth  in 
one  or  another  jaw,  and  is  met  with,  more  frequently,  in  persons 
of  middle  age,  and  may  last  several  months,  even  years.  At 
last  all  the  teeth  in  the  jaw  become  loose  and  are  lost.  While 
the  latter  effect  is  being  produced,  the  inflammatory  symptoms 
in  the  gums  often  disappear  apparently;  but  if  pressure  be  made 
Avith  the  finger  along  the  root,  towards  the  neck  of  the  tooth,  a 
tenacious  gelatinous  fluid  oozes  out,  indicating  the  existence  of 
the  inflammatory  affection.  The  latter  secretion  invariably  ap- 
pears, first  of  all,  upon  the  facial  segment  of  the  gums,  but  later 
is  found  also  upon  the  lingual.  Albrecht  is  of  the  opinion,  that 
the  pressure  of  the  tongue  and  its  constant  sucking  action  upon 
the  lingual  surfaces  of  the  alveolar  processes,  prevent  the  accu- 
mulation of  the  purulent  matter,  and  that  pressure  by  the  finger 
upon  the  latter  surfaces  does  not  give  vent  to  a  puriform  fluid, 
unless  the  affection  is  very  far  advanced.  In  these  cases,  then, 
we  have  to  do,  first  of  all,  Avith  a  catarrhal  inflammation  of  the 
gum,  which  afterwards  extends  to  the  root-membrane. 

In  very  acute  cases  the  inflamed  root-membrane  degenerates 
into  an  unctuous,  fetid,  ichorous,  pulpy  covering  of  the  surface 
of  the  root,  i.  c,  it  undergoes  gangrenous  metamor pilosis.  In 
such  cases  we  find  a  clouded,  dirty-yellow  or  broAvnish-yellow, 
granular  mass  (detritus),  containing,  usually,  shrivelled  nuclei 
which  are  barely  recognizable,  and  numberless  rod-shaped, 
slender,  occasionally  undulating  bodies  (Bacteria)  which  were 
regarded  by  Pasteur  as  a  putrefactive  ferment. 

If  we  bear  in  mind  the  intimate  connection  of  the  root-mem- 
brane with  the  vessels  and  nerves  of  the  pulp,  which  has  been 
referred  to  repeatedly,  also  with  bloodvessels  which  enter  from, 
and  return  through  the  alveolar  walls,  and  with  nerves  coming 
from  the  foramen  in  the  alveolus  and  the  intra-alveolar  canal, 
it  is  easy  to  understand  that  an  inflammatory  condition  of  the 

■**  Toirac.  and  subsequently  Desirabode. 


212  INFLAMMATIONS. 

root-membrane  cannot  persist  without  implicating  the  adjacent 
structures. 

The  changes  in  the  hard  tissues  of  the  root,  which  occur  chiefly 
with  chronic  suppurating  inflammation  of  the  periosteum  of  the 
root,  consist  in  necrosis  and  resorption,  according  to  the  nature 
of  the  tissue.  If  the  superficial  cement  be  not  discolored,  dull, 
whitish,  indistinct  spots  may  be  observed,  sometimes,  incorpo- 
rated in  it.  If  these  are  cut  out  in  thin  plates  and  examined  with 
transmitted  light,  they  present  a  clouded  dirty  yellow,  brownish- 
yellow,  and  from  this  to  a  black-brown  color.  The  bone-cor- 
puscles become  less  discernible  in  the  mass  as  the  transparency 
diminishes;  the  intercorpuscular  substance  is  transformed  chiefly 
into  a  minutely  granular  mass,  and  frequently  has  a  foraminated 
appearance. 

In  consequence  of  resorption  following  suppuration,  the  outer 
surface  of  the  root  becomes  rough,  sometimes,  as  it  were,  cor- 
roded, covered  with  irregular  excavations;  its  extremity  is  hol- 
lowed out  like  a  funnel  at  the  part  corresponding  with  the 
entrance  to  the  canal,  or  sharpened  to  a  point,  like  a  needle. 
The  histological  appearances  produced  by  the  process  of  resorp- 
tion are  displayed  in  a  manner  similar  to  those  which  were  ob- 
served in  the  resorption  of  the  roots  of  the  milk  teeth,  i.  e.,  there 
are  circumscribed  depressions  upon  the  outer  surface  of  the 
cement,  which  are  made  up  of  groups  of  closely  approximated, 
shallow,  cup-shaped  indentations.  In  the  ridge-like  elevations 
which  bound  the  excavations,  well-preserved  bone-corpuscles 
are  to  be  found,  while  they  become  gradually  less  discernible  in 
the  deeper  portions.  Necrosis  of  the  cement  not  infrequently 
is  associated  with  resorption,  in  which  cases  sections  made  in 
directions  perpendicular  to  the  surface  of  the  root  present  spots 
of  a  dark  color  and  with  obscurely  defined  margins  between  the 
excavations  produced  by  resorption. 

If  the  cement  is  entirely  destroyed  (usurirt),  here  and  there, 
by  the  suppuration,  the  dentine  becomes  similarly  aff'ected  and 
acquires  a  roughened  or  corroded  appearance.  If  the  aff'ected 
portions  are  examined  carefully,  they  will  be  found  to  be  irregu- 
larly notched  with  numerous  cup-shaped  excavations  with  sharp 
outlines,  which  sink  into  the  dentinal  substance,  are  crowded 


ETIOLOGY    OF    INFLAMMATION    OF    ROOT -MEMBRANE.     213 

together,  frequently  into  groups,  and  contain  the  corroding  pus. 
The  adjacent  portions  of  the  dentine,  with  the  tubules  running 
from  them,  retain  their  normal  transparency.  The  indentations 
themselves  are  lined  with  a  molecular  mass  which,  frequently,  is 
impregnated  with  a  yellow,  or  brownish-yellow  coloring  matter; 
their  projecting  margins  are  delicately  notched  ;  their  exposed 
surfaces  are  occupied  by  transversely  and  obliquely-divided  den- 
tinal tubules  (Atlas,  Fig.  115).  There  are,  consequently,  no 
indications  of  a  vital  action  on  the  part  of  the  dentine.  The 
theories  advanced  to  explain  the  manner  in  which  the  excava- 
tions are  produced  by  resorption  are  mere  suppositions ;  they 
may  be  regarded  as  induced  either  by  the  activity  of  the  pus- 
corpuscles,  or  by  a  fermentation  process;  with  regard  to  the 
former,  it  is  conceivable,  that  the  amoeboid  movements  of  the 
corpuscles  might  wear  away  the  dental  substances;  in  the  latter 
case,  the  generation  of  an  organic  acid  might  be  assumed.  In 
chronic  cases,  the  eroded  portions  are  covered  by  a  thin  mem- 
brane of  connective  tissue  or  by  a  layer  of  granulation  tissue. 

Sometimes,  on  the  other  hand,  the  inflammation  spreads  from 
the  root-membrane  to  the  socket  of  the  tooth;  when  this  occurs, 
the  canals  of  the  latter  in  the  vicinity  of  the  focus  of  suppura- 
tion become  expanded  ;  excavations,  in  the  form  of  pits  and 
grooves,  are  formed  in  it,  and,  finally,  there  ensues  a  partial 
resorption  of  the  alveolus,  which  process  is  induced  by  the  pro- 
liferation of  the  elementary  organs  of  the  connective  tissue. 

Etiology  of  Injiammation  of  the  Root-Membrane. — The  most 
common  origin  is  a  pre-existing  injiammation  of  the  piilp  which 
itself  is  produced  by  penetrating  caries,  in  most  cases.  Hence 
the  affection  becomes  a  complicated  one.  The  cause  of  the  sub- 
sequent inflammation  of  the  root-membrane  is  to  be  found,  as 
has  been  observed  before,  in  the  direct  transmission  of  the  irri- 
tation from  the  inflamed  nerves  and  vessels  of  the  pulp  to  those 
of  the  periosteum  of  the  root.  If  the  pulp  be  irritated  by  a  too 
early  filling  of  a  carious  cavity,  or  if  the  escape  of  the  pus  from 
an  inflamed  and  exposed  pulp  be  prevented  by  filling,  symptoms 
of  the  inflammmation  of  the  root-membrane  are  very  likely  to 
occur,  since  the  decomposing  pus  rises  or  sinks  within  the  canal 


214  INFLAMMATIONS. 

of  the  root,  and  acts  as  a  strong  irritant  upon  the  portion  of  the 
membrane  at  the  extremity  of  the  root. 

Persons  who  work  in  match-factories,  where  they  are  exposed 
to  the  fu)7ies  of  jjhospJwrus,  are  liable  to  be  attacked  with  inflam- 
mation of  the  root-periosteum,  if  they  have  carious  teeth.  The 
affection  always  originates,'  asserts  Albrecht,  at  a  part  where 
the  fumes  of  phosphorus  have  access  to  the  membranes  covering 
the  bone,  and,  in  the  mouth,  the  best  opportunity  for  this  end 
is  afforded  by  the  diseased  teeth  in  which  the  pulp-cavities  have 
become  exposed.  The  noxious  element  is  carried  to  the  part 
chiefly  by  the  saliva  which  becomes  saturated  with  the  fumes,  as 
is  manifested  even  by  the  characteristic  penetrating  odor  that 
escapes  from  the  mouth,  by  means  of  which  alone  a  worker  in 
phosphorus  may  be  recognized ;  further,  by  the  inspired  air 
which,  on  expiration,  frequently  becomes  luminous  in  the  dark. 
The  pus  of  phosphornecrosis  is  said  to  contain  a  large  amount 
of  phosphorus,  the  truth  of  which  assertion,  however,  Hoppe- 
Seyler  considers  very  doubtful.  The  fumes  themselves  appear 
to  exercise  no  destructive  effects  upon  the  hard  dental  tissues ; 
I  have  noticed  merely  a  blue-gray  tinge.  Albrecht  observed  a 
faceted  appearance  upon  the  extremities  of  the  roots,  if  the  teeth 
are  retained  for  a  considerable  period.  An  hypertrophy  of  the 
cement  appears  not  to  take  place,  nor  does  a  destruction  of  the 
cement  layer  occur,  probably  because  the  process  runs  its  course, 
producing  a  complete  destruction  of  the  root-membrane,  too 
quickly  ;  the  roots  appear  to  him  to  be  somewhat  more  trans- 
parent at  their  extremities,  and  of  a  horny  character. 

The  extension  of  the  inflammation  of  the  periosteum  of  the 
root  of  one  tooth  to  that  of  the  adjacent  one  is  effected  by  means 
of  the  periosteum  of  the  jaw,  which  becomes  swollen  contempo- 
raneously with  the  former  and,  like  it,  is  destroyed,  "  absceded" 
(abscedirt).  In  cases,  where  the  jaw  contains  no  carious  tooth, 
and  still  inflammation  of  the  root-periosteum  occurs,  as  an  effect 
of  the  fumes  of  phosphorus,  the  saliva,  impregnated  with  the 
latter,  affects  the  gums  primarily,  and  then  the  root-membrane. 

The  inflammatory  affections  of  the  gums  hereby  induced  spread 
also  to  the  root-membrane;  this  occurs  more  frequently  with  the 
teeth  of  the  lower  jaw,  because  pus  or  sanious  matter  accumulates 


ETIOLOGY    OF    INFLAMMATION    OF    ROOT -MEMBRANE.     215 

more  readily  in  the  pouches  formed  by  the  gums  of  these  teeth, 
and  produces  an  irritation  upon  the  root-membrane  which  is  in 
immediate  contact  with  the  submucous  connective  tissue  of  the 
gums.  Consequently  the  original  cause  of  this  inflammation  of 
the  root-membrane  is  the  same  with  that  of  the  inflammatory 
affection  of  the  gums. 

McrcuTD^  likewise,  acts  upon  the  root-membrane  through  the 
gums,  and  may  even  affect  the  whole  set  of  teeth ;  but  the  teeth 
of  the  under  jaw,  which  are  bathed  with  the  saliva,  are  the 
soonest  involved.  The  teeth  are  lifted  out  of  their  alveoli,  with- 
out any  special  sensations  of  pain,  in  consequence  of  the  swelling 
of  the  root-membrane,  and,  as  the  process  advances,  they  become 
loosened  so  much  that  they  are  easily  separated  from  the  alveoli. 
The  root-membrane  is  then  found  to  be  covered  with  a  tenacious 
unctuous,  viscid  mass.* 

Mechanical  causes,  e.  g.,  a  kick  or  blow,  dental  operations 
which  are  not  conducted  with  proper  care,  especially  with  per- 
sons who  are  very  susceptible  to  injuries  of  any  kind,  a  ligature 
around  the  neck  of  the  tooth,  foreign  bodies  which  become  forced 
into  the  pouches  formed  by  the  gums  or  into  the  root-canals  of 
carious  teeth,  e.  g.,  bits  of  toothpicks,  stumps  of  teeth  which 
have  become  fastened  to  the  root,  concussion  of  the  jaw  from  a 
fall,  &c.,  may  give  rise  to  an  inflammation  of  the  root-membrane 
and  are  more  likely  to  do  so,  if  the  latter  is  in  an  irritated  con- 
dition previously.  Pressure  in  chewing,  exerted  in  an  abnormal 
direction  upon  one  or  another  surface  of  the  roots  of  an  obliquely- 
located  tooth  by  its  antagonist,  may  irritate  the  root-membrane 
and  lead  to  an  inflammation.  In  a  wisdom  tooth,  with  its  crown 
inclined  anteriorly  and  impinging  upon  the  second  molar,  the 
root-membrane  is  exposed  to  injury  in  consequence  of  the  con- 
cussion occasioned  during  the  act  of  mastication.  Albrecht 
mentions  a  case,  which  came  under  his  observation,  of  an  in- 
flammation of  the  root-membrane  of  the  milk  molars,  which  was 

*  Albrecht  states,  that  several  other  substances  may  produce  similar 
effects,  but  that  it  is  not  such  a  common  occurrence  with  them  as  it  is  with 
mercury.  Affections  of  the  root-membrane  have  been  observed  following 
the  use  of  preparations  of  gold,  copper,  arsenic,  antimony,  iodine,  and  the 
employment  of  digitalis  and  opium,  castor  and  croton  oil,  and  cantharides. 


216  INFLAMMATIONS. 

induced  in  consequence  of  the  advance  of  the  permanent  bicus- 
pids prior  to  the  complete  resorption  of  the  roots  of  the  milk 
teeth. 

In  replantation  of  children's  teeth  which  have  been  forced 
from  their  alveoli  in  surgical  operations  or  separated  from  their 
alveoli,  without  any  fracture  of  the  same,  by  a  kick,  fall,  or 
blow,  it  is  well  known,  that  they  will  become  fixed  under  favor- 
able circumstances,  more  readily,  to  be  sure,  when  the  interval 
of  time  is  short  and  the  teeth  remain  attached  to  the  gums. 
Transplantation  of  the  teeth  of  different  individuals,  immediately 
after  their  extraction,  as  Hunter  proposed,  does  not,  on  the  whole, 
furnish  favorable  results,  since  the  roots  of  corresponding  teeth, 
in  different  individuals,  vary  so  much  in  thickness,  length,  and 
curvation  ;  consequently,  the  alveolus  is  either  injured  or  in- 
completely filled,  and  the  subsequent  inflammatory  processes 
prevent  the  desired  fixation.  Mitscherlich*  relates  instances 
of  partially  successful  results  from  the  implantation  of  dead 
teeth,  in  which  cases  the  inserted  tooth  becomes  fastened  by 
osseous  tissue  which  grows  into  the  dentine  from  the  maxillary 
surface. 

The  root-membrane  is  subject,  also,  to  a  rheumatic  affection 
which  may  be  either  primary  or  secondary:  in  the  former  case, 
it  remains  localized  or  spreads  to  the  periosteum  of  the  jaw  ;  it 
is  accompanied  by  other  rheumatic  symptoms.  In  the  second 
case  it  extends  from  the  periosteum  of  the  jaw  to  that  of  the 
root,  and  involves  the  whole  set  of  teeth.  The  pains  have  no 
special  character,  so  that  it  is  impossible  to  speak  of  a  typical, 
rheumatic  toothache.  Almost  always  there  are  one  or  more  un- 
sound teeth,  whose  diseased  periosteal  membranes  excite  a  con- 
secutive swelling  of  the  maxillary  periosteum  with  the  symptoms 
of  rheumatism. 

Alveolar  Abscess. — When  an  abscess  of  the  periosteum  at 
the  extremity  of  the  root  is  left  to  itself,  and  there  is  no  exit 
for  the  pus,  either  through  the  root-canal  and  exposed  pulp- 
cavity  or  along  the  surface  of  the  tooth  to  the  margin  of  the 
gums,  one  side  of  the  alveolus,  particularly  in  debilitated  per- 

*  Laiigenbeck's  Archiv.  fiir  Cliirurgie,  1862. 


ALVEOLAR    ABSCESS.  217 

sons,  undergoes  a  complete  resorption  from  the  proliferation  of 
the  connective-tissue  cells  in  the  wall  of  the  abscess  or  from  the 
eroding  pus ;  that  portion  of  the  maxillary  wall  which  incloses 
the  alveolus,  together  with  its  periosteum,  becomes  involved 
Avithin  the  limits  of  the  abscess.  A  suppurating  ("  absceding") 
periostitis  is  produced,  the  subsequent  progress  of  which  is 
modified  by  the  special  local  relations. 

It  is  not  an  infrequent  occurrence  for  a  purulent  infiltration 
into  the  spongy,  osseous  tissue  surrounding  the  alveoli  to  take 
place,  and  the  more  abundant  this  tissue  is,  the  greater  is  the 
liability  to  the  occurrence  of  infiltration.  When  the  necrotic 
pus  has  perforated  the  maxillary  periosteum,  it  flows  downwards 
from  its  OAvn  weight,  in  the  loose  connective  tissue,  unless  its 
course  is  obstructed,  when  it  seeks  an  exit  in  another  direction, 
which  is  governed  by  the  local  anatomical  relations.  The  fis- 
tulous track  not  infrequently  attains  a  remarkable  length  and 
terminates  in  a  fistulous  ulcer  upon  the  external  integument,  in 
the  mucous  membrane  of  the  cavity  of  the  mouth,  or  in  some 
other  cavity.  The  arrest  of  this  affection,  which  lasts  some- 
times for  years,  not  infrequently  endangers  life  and  often  is 
not  fully  recognized  by  physicians,  can  only  be  eifected  by 
operative  interference,  which  is  to  be  determined  by  a  thorough 
examination  of  all  the  parts  involved  in  the  region  of  the  oral 
cavity. 

An  abscess,  originating  at  the  closed  extremities  of  the  root- 
membranes  of  the  incisors  of  the  upper  j<^w,  generally  perfor- 
ates the  anterior  alveolar  wall  at  a  point  corresponding  to  the 
apex  of  the  root.  The  periosteal  portion  of  the  gums  becomes 
conjointly  involved,  and  a  fistulous  track  is  formed  which  opens 
in  the  outer  cavity  of  the  mouth  upon  the  facial  surface  of  the 
gum,  and  more  or  less  below  the  level  of  the  focus  of  suppura- 
tion. The  pain  ceases  as  soon  as  an  exit  for  the  pus  is  aiforded. 
The  cavity  of  the  abscess  attains,  on  an  average,  half  the  size 
of  a  split  pea,  and  is  lined  with  a  membraniforra  layer  of  con- 
nective tissue.  In  the  skeleton,  the  former  cavity  of  an  abscess 
presents  a  sharp  outline  ;  its  rounded  internal  surface,  tolerably 
smooth,  presents  indentations  which  result  from  the  eroded  can- 
celli  (Atlas,  Fig.  124).     When  the  central  incisors  are  afi'ected, 


218  INFLAMMATIONS. 

the  incisive  canul  on  the  corresponding  side,  also,  becomes  in- 
volved, subsequent  to  the  destruction  of  the  inner  alveolar  wall. 
The  cavity  of  the  abscess  sometimes,  also,  takes  an  upward  course^ 
upon  the  incisors,  and  perforates  the  floor  of  the  nasal  cavity.  ) 
The  opening  in  the  anterior  segment  of  the  osseous  floor  ac- 
quires the  size  of  a  lentil  or  pea.  Not  infrequently  the  pus- 
sac  extends  downwards  and  backwards  in  the  direction  of  the 
inner  cavity  of  the  mouth,  and  occasions  resorption  of  the  thick 
osseous  layer  in  the  most  anterior  portion  of  the  hard  palate,  in 
consequence  of  which,  a  round  hole,  sometimes,  of  considerable 
size,  is  formed.  Within  the  pus-cavity,  projects  the  root  of  one 
or  those  of  both,  incisors  (Atlas,  Fig.  125).  The  margins  of 
the  hole,  in  the  palatal  process,  are  smooth,  rounded  or  sharp 
at  the  edges,  as  if  cut  with  a  knife.  Sometimes,  it  also  hap- 
pens, that  the  same  abscess  spreads  in  all  the  three  above-men- 
tioned directions,  towards  the  labial,  nasal,  and  palatal  surfaces, 
and  perforates  the  cortical,  osseous  layers.  As  a  result  of  this, 
the  outer  (vestibulum  oris)  and  inner  cavities  of  the  mouth,  and 
the  nasal  cavity  upon  the  aff'ected  side  communicate  with  each 
other  by  means  of  fistulous  tracks  (Atlas,  Fig.  126),* 

Several  cases  of  aneurism  of  the  superior  palatine  artery 
have  been  observed,  which  admonish  us  to  be  on  our  guard 
against  making  a  too  hasty  diagnosis  and  opening  an  imaginary 
abscess. 

The  upper  canine  teeth  are  less  frequently  the  subjects  of  a 
suppurative  inflammation  of  the  root-membrane.  When  they 
are  attacked,  the  disease  is,  generally,  an  extension  from  the  lat- 
eral incisor,  or  from  the  first  bicuspid,  and  there  are  pathological 
specimens  of  these  spreading  abscesses  in  which  whole  rows  of 
roots  are  exposed,  by  the  melting  away  (Schmelzung)  of  the 
anterior  or  posterior  maxillary  wall. 

Sewillf  reports  a  case  of  a  fistulous  opening  at  the  inner 
canthus  of  the  right  eye  of  a  child,  ten  years  of  age.  There 
had  been  a  constant  purulent  discharge  from  the  opening  for 
some  months,  and,  to  all  appearances,  it  resembled  a  lachrymal 

*  Teirlink,  Castle,  Herapath. 

•f  Odontological  Society  of  Great  Britain,  1868. 


ALVEOLAR    ABSCESS.  219 

fistula.  The  sound  -was  passed  into  the  opening,  and  it  extended 
as  fjir  as  the  canine  tooth,  -which  was  discolored.  This  tooth 
was  extracted  and  recovery  speedily  ensued. 

Alveolar  abscesses  upon  the  upper  bicuspids  and  jnolars  com- 
monly open  upon  the  facial  wall  of  the  jaw,  and  it  is  not  un- 
common to  find  the  extremities  of  several  roots  projecting  into 
the  cavity  of  the  same  abscess.  Sometimes,  the  cortical  layer 
of  the  external  maxillary  wall  is  raised  in  the  form  of  a  pro- 
jecting wall,  with  a  sharp  edge,  towards  the  cavity  of  the  ab- 
scess (Atlas,  Fig.  127).  Occasionally,  the  lingual  portion  of 
the  alveolar  process  presents  a  breach  in  the  osseous  substance 
which  is  bounded  b}''  sharp  edges  and  corresponds  with  the  par- 
tially denuded,  carious  roots  of  the  molars. 

After  the  pus  has  undermined  or  perforated  the  periosteum 
of  the  jaw,  it  forces  its  way  along  the  connective-tissue  sheaths 
of  the  muscles  and,  not  infrequently,  escapes  externally  through 
the  integument  (buccal  fistula),  or  penetrates  the  parotid  gland 
and  produces  a  salivary  fistula.  If  the  extremities  of  the  roots 
project  far  into  the  antrum,  the  pus  may  perforate  the  mucous 
membrane  and  escape  into  the  cavity  or,  if  the  teeth  or  roots 
are  extracted,  give  rise  to  a  fistula  of  the  antrum,  which  is  dis- 
played in  the  skeleton  as  a  funnel-shaped  depression  with  a 
corresponding  opening  in  the  floor  of  the  cavity.  The  maxil- 
lary tuberosity  frequently  becomes  infiltrated  with  the  pus  from 
the  abscesses  of  the  roots  of  the  upper  wisdom  teeth  (Atlas, 
Fig.  139).  J.  A.  Salter*  relates  the  following  grossly  neglected 
case  of  inflammation  of  the  root-membrane  of  an  upper  molar. 
A  female,  twenty-four  years  of  age,  Avas  attacked  with  a  severe 
toothache,  referred  to  the  first  upper  molar  on  the  right  side, 
the  pain  being  accompanied  by  an  extensive  swelling  of  the 
same  side  of  the  face  and  attended  with  intense  suffering.  The 
eyeball  became  protruded,  and  she  soon  noticed,  that  she  was 
unable  to  see  with  that  eye.  In  a  short  time  after  this,  the  ab- 
scess pointed  in  the  vicinity  of  the  inner,  and  later  near  the 
outer  canthus,  and  a  large  quantity  of  pus  escaped.  The  open- 
ings then  closed  again  and  the  general  symptoms  remained  the 

*  Medical  Times,  1862. 


220  INFLAMMATIONS. 

same.  The  latter  condition  continued  three  weeks.  On  ad- 
mittance to  the  hospital,  the  patient  presented  a  repulsive  dis- 
figurement of  the  face,  oedema  of  the  lids,  livid  skin.  The  first 
upper  molar  on  the  right  side,  together  with  other  carious  teeth, 
were  removed,  and  the  antrum  could  be  reached  through  the 
partially  absorbed  alveolus  of  the  first  tooth.  There  was  con- 
siderable necrosed  bone,  including  a  large  portion  of  the  inner 
and  outer  walls  of  the  orbit,  which  was  separated.  The  mo- 
bility of  the  iris  was  restored,  but  not  vision.  The  author  re- 
lates an  analogous  case  from  the  practice  of  Pollock,  where 
there  was  an  intense  inflammation  of  the  whole  maxillary 
region,  occasioned  by  a  carious  tooth  ;  it  involved  also  the  or- 
gans in  the  orbit.  The  inflammation  yielded  after  the  extrac- 
tion of  the  tooth,  but  the  power  of  sight  Avas  lost. 

C.  Williams*  reports  a  case  of  an  alveolar  abscess,  which 
occurred  subsequent  to  the  extraction  of  an  upper  molar  and 
opened  upon  the  inferior  margin  of  the  orbit,  just  beneath  the 
outer  commissure  of  the  eyelids.  The  pus  made  its  way  beneath 
the  zygomatic  process  along  the  temporal  muscle,  its  escape  in 
the  temporal  region  being  prevented  by  the  latter  and  the 
strong  fascia  investing  it;  it  made  its  way  through  the  spheno- 
maxillary fissure  into  the  outer  and  lower  portion  of  the  orbits, 
and  escaped  by  means  of  a  fistulous  opening.  There  was 
marked  exophthalmia  of  the  left  eye,  combined  Avith  serous 
chemosis.  After  the  pus  was  evacuated  by  means  of  incisions 
in  the  temporal  region,  improvement  soon  followed. 

Abscesses  of  the  periosteum  of  the  roots  of  the  under  teeth, 
perforate  the  facial,  more  frequently  than  the  lingual  wall  of 
the  jaw.  The  molars,  however,  form  an  exception  to  this  rule. 
Destructive  processes  in  the  bone  are  less  intensive  and  exten- 
sive than  in  the  upper  jaw.  Still  it  is  not  uncommon  for  the 
entire  facial  wall,  both  of  the  alveoli  and  the  jaw  to  be  de- 
stroyed ;  the  lingual  wall,  also,  of  the  lower  jaw  is  frequently 
perforated,  especially  opposite  the  apices  of  the  roots  of  the  in- 
cisors. The  margins  of  the  bone,  which  bounds  the  parts  where 
destruction  has  taken  place,  always  terminate  in  thin  edges  and, 
generally,  have  an  oblique  direction  from  below  upwards. 

*  Dental  Cosmos,  1867. 


ALVEOLAR    ABSCESS.  221 

With  abscesses  of  the  periosteum  of  the  roots  of  the  under 
teeth,  there  is,  always,  great  danger  of  the  formation  of  fistulous 
tracks  along  the  fasciae  and,  whether  the  fistulfe  open  upon  the 
cheek  (salivary  fistulae),  upon  the  margin  of  the  lower  jaw,  in 
front  of  or  behind  the  ear,  in  the  cervical  region,  upon  the  nape 
of  the  neck  or  the  thorax,  their  true  character,  frequently,  is 
not  recognized  by  physicians,  and  they  are  improperly  treated. 

In  proof  of  this  fact,  may  be  cited  the  following  communica- 
tion, which  was  made  to  me  by  Prof.  Strasky  :  "  Several  years 
ago,  I  was  consulted  by  an  elderly  lady  in  regard  to  a  set  of 
artificial  teeth.  Presently,  to  my  surprise,  she  began  to  arrange 
the  dressing  of  a  purulent  ulcer,  upon  the  left  side  of  the  chest, 
opposite  the  armpit,  in  the  region  of  the  fourth  or  fifth  rib.  To 
my  question,  as  to  what  ailed  her,  she  replied,  that  for  three 
years,  she  had  been  under  the  care  of  the  most  noted  physicians 
in  the  city,  who  had  treated  this  ulcer  with  all  sorts  of  salves 
and  plasters,  but  to  no  purpose,  for  the  ulcer  which  commenced 
as  a  small  abscess,  gradually  increased  in  size,  and  became 
more  painful.  When  I  examined  the  mouth  for  the  purpose  of 
fitting  the  set  of  teeth,  I  found  the  left  lower  wisdom  tooth 
deeply  imbedded  within  the  gums;  the  crown  was  quite  de- 
stroyed by  caries,  the  gums  around  it  were  detached,  sensitive, 
and,  upon  pressure,  pus  oozed  out  from  them.  As  I  had  pre- 
viously conjectured  that  the  ulcer  upon  the  thorax  was  de- 
pendent upon  an  affection  of  the  tooth,  I  applied  pressure  from 
the  angle  of  the  jaAv  along  the  surface  of  the  neck  to  the  region 
of  the  ulcer,  and  became  satisfied  that  pus  escaped  from  two 
points  of  the  ulcerated  surface.  The  carious  tooth  was  ex- 
tracted, and  the  ulcer  healed  in  the  course  of  a  few  weeks," 

Pagello*  had  under  treatment  a  fistula  which  opened  in  the 
dimple  of  the  chin  and  resisted  every  kind  of  treatment.  The 
teeth,  apparently,  were  sound.  An  infusion  of  madder  was  in- 
jected into  the  fistulous  track,  and,  in  a  few  days,  the  incisor, 
situated  above  the  track,  acquired  a  red  color.  The  tooth  was 
extracted,  and  the  fistula  speedily  and  entirely  healed. 

Finally,  it  may  be  remarked,  that  inflammations  of  the  peri- 

*  L'jibeille  Medicale,  1856. 


222  INFLAMMATIONS. 

ostcum  of  the  root,  rcsultinf;  in  abscesses  and  erosions  of  the 
jaw  or  tooth,  occur  also  in  animals.  I  have  had  the  opportunity 
of  observing  instances  of  this  kind  in  the  horse  and  dog.  In 
these  cases,  caries  does  not  furnish  the  starting-point,  as  is, 
usually,  the  case  in  man. 

Inflammatory  affections  of  the  periosteum  of  the  jaAV  are  of 
frequent  occurrence,  as  a  sequence  of  an  inflammation  of  the 
pulp  or  root-membrane. 

The  cases  that,  for  the  most  part,  come  under  the  notice  of 
dentists,  are  those  of  periostitis  occurring  upon  the  alveolar 
process  as  a  sequence  of  caries  of  the  teeth  and  which  is  con- 
fined within  narrow  limits,  though  to  be  sure,  now  and  then,  it 
is  quite  extensive.  This  inflammation  is  manifested  primarily 
by  the  appearance  of  a  tumor  upon  the  bone,  which  is  occa- 
sioned by  an  oederaatous  swelling  in  the  perimysium  and  subcu- 
taneous connective  tissue,  in  consequence  of  a  hindrance  to  the 
circulation.  If  purulent  infiltration  into  the  alveolus  has  taken 
place,  the  maxillary  periosteum  readily  becomes  similarly  af- 
fected. Hence  is  developed  a  circumscribed  periostitis,  which 
ends  in  suppuration  and  destroys  the  contiguous  portions  of  the 
bone  (Atlas,  Figs.  124-127  inclusive). 

Inflammations  of  the  maxillary  periosteum  of  this  descrip- 
tion are  of  frequent  occurrence  and  are  very  much  neglected, 
after  the  subsequent  suppuration,  especially  by  patients  of  the 
poorer  classes,  since,  if  the  pus  has  a  free  exit,  the  sensitive- 
ness of  the  bone  persists,  to  be  sure,  but  the  pain  is  not  of  such 
a  severe  character  as  to  compel  the  patient  to  appl}^  for  relief. 
When  the  pus  has  a  free  exit,  the  face  even  is  not  perceptibly 
disfigured.  The  inflammation  may  assume  an  acute  character 
and  give  rise  to  an  abundant  purulent  mass,  which  undermines 
the  neighboring  periosteum,  cuts  off  the  vascular  supply  to  the 
corresponding  segment  of  the  jaw,  and  hence  occasions  a  ne- 
crosis of  the  latter. 

"When  the  suppurating  periostitis,  especially  in  neglected  or 
badly  treated  cases,  has  occasioned  the  death  of  the  subjacent 
bone,  the  dead  portion  acts  as  a  foreign  body  and  induces  a 
consecutive  suppuration  in  its  vicinity.  A  fistula  is  formed, 
leading  to  the  necrosed  portion  of  the  alveolar  process.     The 


ALVEOLAR    ABSCESS — PERIOSTITIS.  223 

detachment  of  the  sequestrum  is  a  slow  process  and,  often,  does 
not  occur  for  months,  recurrences  of  the  inflammation  beino; 
vei'y  frequent.  A  repair  of  the  destroyed  portion  of  the  bone 
takes  place  in  most  cases. 

It  is  a  familiar  fact,  that  the  alveolar  process  is  fractured, 
not  infrequently,  by  carelessness  in  the  extraction  of  teeth,  es- 
pecially of  the  lower  molars.  Unfavorable  circumstances,  for 
instance,  deep  position  of  the  teeth,  hooked  roots,  notable  di- 
vergence or  length  of  the  same,  mai'ked  fragility  of  the  bone 
in  persons  of  advanced  age,  render  a  fracture  of  the  process 
possible,  even  with  the  utmost  care  in  extraction.  When  a 
fracture  occurs,  it  depends  upon  its  extent  and  complexity, 
whether  or  not  several  teeth,  together  with  their  alveoli,  will 
become  necrosed.  As  a  general  rule,  a  slight  splintered  fracture 
readily  heals,  after  the  exfoliation  of  the  fragments.  Stumps 
of  teeth  and  the  attached  root-membranes,  which  remain  after 
ineffectual  attempts  at  extraction,  not  infrequently  give  rise  to 
a  localized  periostitis,  which  is  recovered  from  as  soon  as  the 
necrosed  stumps  are  extracted  or  expelled.* 

Periosteal  inflammations  occurring  during  the  period  of  den- 
tition are  of  especial  importance,  since,  with  children,  inflam- 
matory affections  generally  run  a  more  rapid  course  than  with 
older  people,  particularly  in  an  organ  in  wliich  development 
takes  place  within  small  limits  with  comparative  rapidity.  The 
more  extensive  the  infiltration  of  the  maxillary  periosteum,  the 
greater  is  the  danger  that  a  larger  portion  of  the  jaw  will  be- 
come necrosed.  Children  of  a  scrofulous  or  tuberculous  habit 
are  the  more  liable  to  the  occurrence  of  partial  necrosis  of  the 
jaws,  from  the  fact  that  in  them  the  infiltration  undergoes  a 
speedy   degeneration   on  account  of  the  rapid  proliferation  of 


*  Leynseele  (Bullet,  clela  Soc.  de  Gand,  1855)  describes  a  case  of  meningo- 
encephalitis which  resulted  from  an  ineffectual  attempt  to  extract  a  tooth. 
The  lower  jaw  was  splintered  at  the  part  where  the  extraction  was  attempted. 
Pus  worked  its  way  along  the  bone,  which  became  denuded,  and  ascended 
upon  the  inner  surface  of  the  ramus  of  the  jaw  to  the  base  of  the  cranium  ; 
it  then  entered  the  cranial  cavity  through  the  foramen  ovale,  spinosum  and 
rotundum,  where  it  spread  out  upon  the  base  of  the  brain  and  became  the 
origin  of  a  meningo-encephalitis. 


224  INFLAMMATIONS. 

the  elementary  organs.  C.  0.  Weber*  relates  two  cases  which 
came  under  his  observation  (in  children  two  and  six  years  of 
age,  respectively),  where  the  periostitis  acquired  alarming  pro- 
portions. 

Children,  who  are  attacked  with  the  eruptive  diseases  during 
the  primary  shedding  of  the  teeth,  especially  when  their  sur- 
roundings are  unfavorable  or  they  are  the  subjects  of  the  above- 
mentioned  diatheses,  are  liable  to  be  affected  with  a  periostitis 
and  necrosis  of  the  jaw  which  Salter|  has  described  as  exanthem- 
atous.  Two  cases  of  this  kind  came  under  his  observation  after 
variola,  five  after  measles,  fifteen  or  sixteen  after  scarlet  fever 
and  most  of  these  cases  occurred  in  children,  five  years  of  age. 

Periostitis  with  necrosis,  occurring  as  a  sequence  of  retarded 
eruption  of  the  wisdom  teeth,  has  already  been  described  [vide 
P-202). 

Rheumatic  periostitis,  which  generally  is  associated  with  cari- 
ous teeth,  is  due  to  exposure  to  cold  and  damp.  Its  symptoms 
do  not  diifer  from  those  of  common  periostitis.  Traumatic  peri- 
ostitis from  fracture  or  contusion  of  the  jaw,  specific,  from  the 
effects  of  phosphorus  or  mercury,  dyscrasic,  which  accompanies 
scorbutus  and  cachexias,  generally,  do  not  usually  come  under 
the  treatment  of  the  dentist,  although,  the  frequent  existence 
of  carious  teeth  and  the  consecutive  inflammation  of  their 
periosteal  membranes  form  an  essential  predisposing  cause,  or 
aggravating  element,  and  require  special  treatment. 

The  symptoms  of  periostitis  of  the  upper  jaw,  induced  by  in- 
flammation of  the  periosteum  of  the  root,  vary  according  to  its 
original  seat.  AlbrechtJ  gives  an  excellent  description  of  them, 
in  the  following  words  :  "  When  the  periosteum  of  the  roots  of 
the  front  teeth  is  involved,  the  alveoli  become  distended,  the  in- 
teralveolar  depressions  disappear,  and  the  inflammation  spreads 
to  the  nasal  cavity  ;  the  secretion  of  the  mucous  membrane  of 
the  latter  is  arrested,  and  its  cartilaginous  portions  become  sen- 
sitive. If  the  affection  extends  from  the  alveoli  of  the  small 
incisors  to  those  of  the  canines  and  bicuspids,  the  irregularities 

*  Handbuch  der  allg.  u.  speciell.  Chirurgie,  redig.  v.  Pitha  und  Billroth, 
t  Surgical  diseases  connected  with  the  teeth  in  Holmes'  System  of  Surgery, 
vol.  iv. 

X  Op.  cit.,  p.  45. 


ALVEOLAR    ABSCESS — PERIOSTITIS.  225 

on  the  facial  sm-face  disappear,  the  canine  fossa  is  obliterated 
and  bulges  out  if  the  intensity  of  the  periostitis  of  the  alveolar 
process  increases  sufficiently,  and  the  periostitis  extends,  usually, 
even  to  the  nasal  process  of  the  upper  jaw,  which  becomes 
somewhat  swollen  and  sensitive  to  pressure.  If  the  inflamma- 
tion starts  from  the  molars  and  bicuspids,  instead  of  a  depres- 
sion, a  firm  swelling  becomes  perceptible  beneath  the  zygoma, 
produced  by  the  swollen,  upper  jaw.  If  the  two  sides  of  the 
face  are  compared  with  each  other,  provided  the  periostitis  is 
not  bilateral,  an  extremely  rare  occurrence,  the  filling  up  of  the 
zygomatic  fossa  becomes  quite  evident  to  the  touch,  even  if  it 
is  inconsiderable.  On  the  other  hand,  the  swelling  may  attain 
such  magnitude,  that  the  surface  of  the  jaw  projects  beyond 
that  of  the  zygoma.  The  inflammation,  sometimes,  extends  far 
beyond  the  afl"ected  tooth.  The  periosteum  of  the  root  may 
return  to  its  normal  condition,  while  the  inflammatory  process, 
or  its  sequelie,  still  persist  in  the  periosteum  of  the  jaw  and 
give  rise,  in  the  latter  locality,  to  important  diseased  processes. 
When  this  occurs,  it  becomes  a  difficult  matter  to  ascertain 
which  tooth  was  the  starting-point  of  the  affection,  as  it  is  often 
requisite  to  remove  this  tooth  in  order  to  afford  an  escape  for 
the  pus  which  is  pent  up  within  the  bone. 

"  Periostitis,  resulting  from  an  extension  of  inflammation, 
occurs  more  frequently  in  the  loiver  jaw  than  in  the  upper. 
After  the  alveolus  of  the  tooth  originally  affected  has  become 
notably  distended  and  painful,  the  ridge,  which  runs  along 
above  the  basilar  portion  of  the  under  jaw  (basis  manibulre), 
disappears  in  the  portions  corresponding  with  the  molars  and 
becomes  continuous  with  the  basis.  The  latter  then  increases 
in  thickness,  becoming,  in  some  cases,  even  five  and  six  times 
as  thick  as  it  is  in  the  normal  condition ;  the  margin  of  the  jaw 
now  presents  a  thick  shapeless  bunch,  which  has  the  hardness 
of  bone  and  spreads  both  to  the  outside  and  to  the  inside 
towards  the  cavity  of  the  mouth.  As  long  as  the  swelling  is 
moderate  in  amount,  it  may  be  known  that  the  process  is  still 
confined  to  the  periosteum  of  the  jaw;  but  when  it  attains  such 
large  dimensions  as  mentioned  above,  either  the  inflammation 
has  extended  to  the  spongy  portion   of  the  bone,  or  purulent 

15 


226  INFLAMMATIONS. 

infiltration  has  taken  place  into  the  bony  tissue  from  the 
alveoli." 

If  we  make  an  anatomical  study  of  jaws  within  which  are 
carious  teeth  and  abscesses  of  the  root-periosteum,  and  observe 
the  frequency  and  marked  degree  of  purulent  infiltration  which 
takes  place  into  the  periosteum  and  bones,  the  suspicion  arises, 
that  there  is  far  from  sufiicient  attention  given  to  this  aff'ection 
by  physicians,  and  that,  perhaps,  many  diseases,  which  termi- 
nate fatally,  originate  from  a  consecutive  suppurative  periostitis 
or  ostitis  of  the  jaws.  Fortunately,  most  cases  of  purulent  in- 
filtration result,  finally,  in  perforation  of  the  maxillary  walls,  and 
the  pus  obtains  a  free  escape  through  the  fistula  which  is  formed 
in  the  gums. 

The  infiltration  of  pus  takes  place  chiefly  in  the  spongy  por- 
tion of  the  osseous  tissue,  and  hence  it  is  found,  in  the  upper 
jaw,  upon  the  lingual  side  of  the  incisors  and  canines  and,  also, 
of  the  bicuspids  and  molars,  especially  between  the  roots  of  the 
latter,  and  in  the  tuberosity.  In  the  lower  jaw,  the  liability  of 
infiltration  is  greater,  since  the  spongy  tissue,  particularly  near 
the  molars,  extends  to  a  considerable  depth  in  the  jaw  and  along 
the  coronoid  processes  and  condyles.  Moreover  the  cortical 
layer  of  .the  bone  is  more  compact,  generally,  so  that  perforation 
by  the  pus  takes  place  with  greater  difficulty. 

In  the  lower  jaw,  the  enlargement  of  the  bone,  in  consequence 
of  purulent  infiltration,  is  most  apparent  on  the  facial  wall,  in 
the  vicinity  of  the  external  oblique  line,  the  latter  becoming 
more  or  less  eff"aced ;  in  the  upper  jaw,  on  the  facial  wall  in  the 
vicinity  of  the  front  teeth  and  towards  the  tuberosity.  The 
cancelli  of  the  bones  are  distended  in  appearance,  of  a  bright 
blood-red  color  or  reddish-gray,  or  discolored.  The  evidences 
of  resorption,  in  consequence  of  the  purulent  infiltration,  are 
displayed  in  the  form  of  sharp-edged  holes,  excavations,  and 
grooves,  upon  the  surfaces  of  the  alveolar  processes,  and  the 
resorption  starts  from  the  Haversian  canals  and  cancelli,  as 
may  easily  be  demonstrated  by  the  graduated  form  presented  in 
the  development  of  the  breaches  in  the  osseous  substance. 

When  a  portion  of  the  alveolar  process  is  destroyed  by  sup- 
puration or  by  necrosis,  a  cicatrization  of  the  remaining  portion 


ALVEOLAR    ABSCESS — PERIOSTITIS.  227 

ensues,  similar  to  that  which  takes  place  after  the  extraction  of 
teeth,  except  that  the  distortion  is  greater,  varying  with  the 
amount  of  the  previous  loss  of  substance,  that  is,  the  cicatrix 
forms  a  deeper  fossa-like  depression  upon  the  alveolar  arch 
(Fig.  78).    The  adjacent  surfaces  of  the  alveoli  of  the  contiguous 

Fig.  78.* 


teeth  are  frequently  defective,  in  consequence  of  which  the  roots 
and  their  periosteal  layers  are  exposed  in  the  cicatrix. 

The  pre-existence  of  a  chronic  periostitis  may  be  clearly  in- 
ferred, even  in  macerated  jaws  after  the  separation  of  the  peri- 
osteum, if  there  is  a  deposit  of  a  minutely-porous  osteophyte 
(comp.  NcAv-formations).  The  very  delicate  and  thin  osteophyte 
formation,  which  may  easily  escape  notice,  is  of  frequent  occur- 
rence and,  generally,  is  limited  to  a  quite  small  circuit  in  the 
vicinity  of  an  alveolar  abscess  ;  upon  the  lower  jaw,  however,  it 
occurs,  at  intervals,  over  the  greater  portion  of  the  facial  wall, 
even  along  the  coronoid  and  articular  processes.    Now  and  then, 

*  Fig.  78  shows  a  segment  of  the  left  lower  maxillary  arch,  in  which  is 
the  cicatrix  of  a  circumscribed  necrosis  of  the  alveolar  process,  corresponding 
to  the  first  and  second  molars.  The  mental  foramen,  somewhat  more  pos- 
teriorly than  usual,  is  situated  underneath  the  apex  of  the  root  of  the  second 
bicuspid  {a).  The  facial  wall  of  the  three  front  teeth  is  removed.  The 
wisdom  tooth  (&)  has  a  forward  inclination,  and  most  of  the  anterior  wall  of 
its  alveolus  is  wanting.  Between  the  latter  tooth  and  the  second  bicuspid, 
a  considerable  loss  of  osseous  substance  is  to  be  seen,  in  the  form  of  a  bowl- 
like fossa,  with  sharp  outlines.  In  the  persisting  portion  of  the  lingual  wall 
of  the  jaw  are  several  holes  of  various  sizes.  The  fossa  was  lined  with  a  thin, 
easily  separable,  connective-tissue  membrane.     Natural  size. 


228  INFLAMMATIONS. 

in  connection  with  caries  of  a  single  tooth,  an  osteophyte  is  met 
Avith  Avhich  extends  along  the  entire  lower  jaw  upon  both  maxil- 
lary walls. 

Chronic  periostitis,  in  the  vicinity  of  the  alveolar  borders, 
frequently  gives  rise  to  proliferations  of  the  compact  osseous 
substance,  Avhich  are  described  in  connection  with  increase  in 
volume,  as  hypertrophy  of  the  alveolar  processes,  or  as  exostoses 
or  osteomata  (comp.  New-formations). 

Nasal  Cavity  and  Antrum. — When  there  is  insufficient  or 
no  escape  for  the  pus  of  abscesses  of  the  root-periosteum  of  the 
upper  incisors  or  canines,  and  the  abscess  spreads  upwards,  the 
bony  floor  of  the  nasal  cavity  becomes  involved,  as  has  already 
been  observed  ;  its  periosteal  covering  and  the  corresponding 
portion  of  the  mucous  membrane  become  inflamed  and  perfora- 
tion, sometimes,  ensues,  by  means  of  which  the  pus  escapes  into 
the  anterior  nasal  region.  The  skeleton,  in  such  cases,  presents, 
usually,  an  oval  aperture,  with  sharp  edges,  the  long  diameter 
of  which,  transversely  disposed,  sometimes  measures  nearly  one 
centimetre,  so  that  it  communicates  with  the  incisive  fossa  on 
the  same  side  (Atlas,  Fig.  126).  In  two  specimens,  I  find  that 
the  abscess  of  the  -root-membrane,  which  penetrated  the  floor  as 
above,  originated  from  the  lateral  incisor.  My  collection  also 
contains  a  specimen,  in  which  the  perforation  is  in  the  middle 
segment  of  the  floor,  adjoining  the  ascending  lateral  wall,  of  the 
nasal  cavity,  and  the  disease  originated  from  a  periosteal  abscess 
of  the  lingual  root  of  the  first  molar.  With  extensive  carious 
affection  of  the  molar  roots,  accompanied  by  chronic  inflamma- 
tion of  the  root-membrane  and  periosteum  of  the  jaw,  the  puru- 
lent infiltration  also  spreads  within  the  osseous  tissue  beyond 
the  floor  of  the  nasal  cavities.  Inflammatory  aff'ections  of  the 
nasal  mucous  membrane,  attended  with  catarrh  or  fistulous 
ulcers,  appear  then  to  be  a  more  frequent  sequence  of  chronic 
inflammatory  diseases  of  the  teeth  than  Avas  formerly  supposed. 

We  sometimes  meet  with  jaws,  in  which  the  lingual  root, 
particularly  of  the  first  molar,  covered  with  a  thin  osseous  layer, 
projects  about  three  to  four  millimetres  beyond  the  floor  of  the 
antrum,  or  where  the  respective  roots  of  the  first  two  molars  or 
that  of  the  second  bicuspid,  covered  with  their  periosteum,  form 


NASAL    CAVITY    AND    ANTRUM.  229 

free  projections  within  the  cavity.  Less  frequently,  humped 
protuberances  are  found  which  are  produced  by  the  roots  of  the 
wisdom  teeth  or  first  bicuspids.  When  such  a  condition  of 
things  occurs,  it  is  easy  to  understand,  that,  as  a  sequence  of 
an  inflammation  of  the  root-membrane  which  ended  in  an  abscess, 
the  purulent  accumulation  has  given  rise  to  an  inflammatory 
aftection  of  the  periosteal  covering  and,  finally,  of  the  mucous 
membrane  of  the  antrum.  Inflammatory^  catarrhal  sioelling  of 
tlie  antru7n,  occurring  either  with  or  without  periosteal  inflam- 
mation of  the  contiguous  teeth,  occasions  a  sensation  of  dull 
pain ;  the  bone  becomes  sensitive,  at  times  even  under  the 
slightest  pressure ;  the  cheeks  become  somewhat  swollen  and 
oedematous,  and,  sometimes,  the  skin  presents  red  spots.  The 
affection  is  now  tei'med  empyema,  and  is  accompanied  by  con- 
tinual pain  with  more  or  less  intense  exacerbations.  T.  Bell 
mentions  the  occurrence  of  caries  (?)  and  exfoliation  of  the  bones, 
in  unfavorable  cases,  especially  in  scrofulous  persons,  and,  ac- 
cording to  his  observations,  if  communication  with  the  nasal 
cavity  becomes  closed,  in  consequence  of  the  swelling  of  the 
mucous  membrane,  the  symptoms  become  more  serious  from  the 
accumulation  of  puriform  mucus ;  the  molars  and  bicuspids,  on 
the  same  side,  become  loosened  and  tilted  from  their  normal 
position,  and  the  gums  swollen  and  spongy.  In  cases,  he  says, 
where  it  cannot  be  expected  that  the  teeth  will  become  firm 
again,  they  should  be  extracted.  Bell  never  saw  a  case  of 
closure  of  the  opening  into  the  nasal  cavity  by  granulations, 
but  mentions  an  instructive  case  of  a  cyst  filled  with  puriform 
mucus.  One  case  of  a  purulent  cyst  of  the  antrum,  in  connec- 
tion with  extensively  carious  roots  of  the  bicuspids  and  molars, 
came  under  my  observation.  When  the  fluid,  accumulated 
within  the  antrum,  had  a  more  serous  character,  the  affection 
used  to  be  called  hi/drops.  In  these  cases,  the  mucus  also  ac- 
quires a  gelatinous  appearance  occasionally. 

As  the  cavity  of  the  antrum  increases  in  extent,  the  facial 
wall  bulges  considerably  and  becomes  quite  thin  and  trans- 
parent. The  distension  may  also  be  perceptible  in  the  direction 
of  the  palate  or  orbit  and,  sometimes,  occasions  a  deviation  of  the 
eye  from  its  normal  position.     As  the  former  attains  increased 


230  INFLAMMATIONS. 

proportions,  the  facial  wall  of  the  bone  undergoes  partial  re- 
sorption, so  that  nothing  is  left  but  a  membranous  wall  hero 
and  there,  and  the  contained  fluid  may  be  determined  by  its 
fluctuation. 

The  diagnosis  is  attended  with  difficulties,  in  some  cases,  and 
the  case  may  easily  be  confounded  with  an  entirely  different 
tumor.  Henry  Smith*  relates  a  case,  where  there  was  a  puru- 
lent collection  in  the  antrum,  forming  a  notable  tumor  which  it 
was  decided  to  extirpate ;  but  it  began  to  improve,  and  the 
operation  was  abandoned.  In  doubtful  cases,  therefore,  it  is 
best,  always,  to  make  a  puncture  into  the  antrum  through  the 
alveolus  of  the  second  molar,  after  extracting  the  tooth,  or 
through  the  canine  fossa.  The  manner  in  which  an  exploratory 
puncture  shall  be  made  depends,  however,  upon  the  special 
circumstances  of  the  case. 

In  favorable  cases,  the  puriform  mucus  escapes  through  the 
nasal  cavity  or  downwards  in  the  alveolar  arch,  if  the  carious 
root  has  fallen  out  or  has  been  extracted.  Sometimes  a  fistu- 
lous track  persists,  which,  frequently,  is  as  fine  as  a  hair  and 
easily  becomes  occluded.  The  discharge  may  also  occur  in  the 
direction  of  the  orbit  or  the  cheek,  and  give  rise  to  an  abscess 
and  necrosis  (comp.  Salter's  case,  above). 

Chronic  irritation  of  the  mucous  membrance  of  the  antrum, 
with  or  without  a  fistulous  track  leading  from  it,  leads  to  thick- 
ening, recurrent,  inflammatory  swellings,  papilliform,  exuberant 
growths  of  connective  tissue,  or  other  kinds  of  new-formations. 

Inflammation  of  this  mucous  membrane  may  also  be  induced 
by  the  penetration  of  foreign  bodies  into  the  antrum,  e.  g.,  tooth 
picks,  stumps  of  teeth  Avhich  have  been  forced  into  it  in  eff"orts 
to  extract  them,  fragments  of  bone  from  fractures  or  gunshot 
wounds,  &c.  Prof.  Strasky,  of  Lemberg,  gave  me  a  brief  account 
of  a  case  of  this  kind.  A  boy  nine  years  old  came  to  him  on 
account  of  pain  in  a  left  milk  molar,  and  an  ulcer  of  the  cheek 
on  the  same  side.  The  father  stated  that  a  year  before,  the 
boy  fell  into  a  Avater  conduit,  one  and  a  half  fathoms  in  depth 
and  framed  with  oaken  posts  and  planks.     After  the  hemorrhage 

*  British  Journal  of  Dental  Science,  18G7. 


NASAL    CAVITY    AND    ANTRUM.  231 

from  the  cheek  was  cliecked,  suppuration  occurred  in  the  cheek, 
and  an  ulcer  Avas  formed,  which  woukl  not  heal,  in  spite  of  very 
careful  treatment.  Strasky  found  a  well-marked  parulis,  and 
extracted  the  painful,  loose  tooth  which  had  pushed  forward  in 
its  socket;  a  probe  was  then  introduced  through  the  socket 
from  which  pus  mixed  with  blood  escaped;  it  easily  passed  into 
the  antrum,  and  by  means  of  it  a  foreign  body  could  be  felt, 
which  could,  also,  be  reached  by  introducing  the  probe  through 
the  ulcer  on  the  cheek.  He  succeeded,  by  means  of  a  pointed 
pair  of  forceps,  in  extracting  the  foreign  body  which  proved  to 
be  a  conical  piece  of  oak  wood,  fifteen  millimetres  in  length 
and  five  millimetres  thick.  The  part  was  carefully  cleansed  by 
syringing,  and  a  sponge-tent  was  introduced,  in  order  to  avoid 
a  premature  closure,  and  kept  in  place  until  the  healing  of  the 
bone  and  skin  took  place.  In  about  three  or  four  weeks,  both 
the  wounds,  that  upon  the  alveolus  and  the  other  upon  the  cheek, 
were  cicatrized. 

F,  Steiner*  reported  a  case  of  dropsy  of  the  antrum,  which 
occurred  in  the  private  practice  of  Prof.  Billroth.  The  affection 
appeared  as  a  sequence  of  a  very  irregular,  extremely  defective 
dentition,  in  a  scrofulous  girl,  sixteen  years  of  age.  The  only 
teeth  that  had  made  their  appearance  in  the  the  upper  jaw  were 
three  temporary  and,  subsequently,  the  three  corresponding  per- 
manent ones.  The  tumor  had  been  forming  for  a  year  in  the 
left  upper  jaw,  and  had  attained  the  dimensions  of  an  apple  of 
medium  size.  The  anterior  wall  of  the  cavity  was  partially 
removed,  and,  on  examination  at  that  part,  no  abnormally  located 
tooth  was  found,  but  on  excision  of  the  posterior  wall  of  the  gum, 
the  imbedded  crown  of  a  bicuspid  was  discovered. 


*  Wiener  med.  Wochenschr.,  1870. 


232  ATROPHIES. 


III.  ATROPHIES. 

Atrophy  of  an  organ  arises  from  a  partial  or  an  entire  per- 
manent Avithdrawal  of  its  nutrition,  and  is  either  jmmary,  senile, 
induced  by  the  gradual  decline  in  the  interchange  of  materials 
incident  to  advancing  age,  or  secondary,  consecutive,  occasioned 
as  a  sequence  of  inflammations,  anomalies  of  the  secretions,  hy- 
pertrophies or  new-formations  in  the  organ  itself  or  outside  in 
the  immediate  vicinity,  or  in  distant  organs  having  a  definite 
relation  with  the  atrophic  organ. 

It  is  scarcely  possible  to  determine  in  every  case,  Avhether  it 
is  one  of  senile,  or  consecutive  atrophy,  and  a  careful  observation 
of  the  clinical  history  of  the  case  can  alone  furnish  a  basis  for 
reasoning,  especially  when  it  is  required  to  determine  the  pre- 
disposing causes  of  the  consecutive  atrophy. 

The  senescence  of  the  organs  of  mastication  needs  to  be  mi- 
nutely studied  in  order  that  the  natural  involution  of  an  organ, 
which  occurs  in  old  age,  may  not  be  confounded  with  a  patho- 
logical process.  The  period  at  which  the  natural  decay  takes 
place  is  not  fixed;  one  organ  may  be  subjected  to  such  unfavor- 
able conditions  of  nutrition  that  either  the  whole  or  parts  decay 
prematurely,  while  the  other  organs  or  the  remaining  portions 
of  the  same  organ  undergo  comparatively  no  alteration  Avithin 
the  same  period.  Premature  decay  is  induced  by  hereditary 
disposition,  excessive  irritation,  and  untimely  abrasion.  In  all 
cases  the  diminished  assimilative  power  of  the  elementary  organs 
gives  rise,  finally,  to  degenerated  products  within  the  proto- 
plasm and  surrounding  substance,  which  products  are  repeated 
in  the  various  organs  except  that  they  occur  under  different 
forms  (Modalitiiten). 

Dental  Pulp. — Diminished  vital  activity  in  the  pulp  is  dis- 
played in  manifold  ways.*  Fatty  degeneration  is  of  frequent 
occurrence  and  is  manifested,  in   a  general  way,  by  its   dimin- 

*  Vide  deutschc  Viertelj.  f.  Zahnheilkunde  5.  Jahrg.  iiber  Atrophicn  dcr 
Zahnpulpe  vuii  M.  Ilcider  und  C.  "VVedl. 


DENTAL    PULP.  233 

islied  volume  and  succulency,  its  recession  and  pale  reddish-gray 
discoloration,  with  a  trace  of  yellow.  These  indications,  of 
course,  are  presented  both  by  the  coronal  and  radical  pulp. 

Pulps  of  this  description  are  covered  by  a  cloudy  layer,  sepa- 
rable in  the  form  of  a  membrane  and  composed  of  degenerated 
dentinal  cells.  The  outlines  of  the  latter  are  preserved,  more 
or  less,  and  they  contain  numerous  luminous  granules  of  various 
sizes,  which  produce  the  optical  eifect  of  fat-globules,  but,  also, 
lie  loose  between  the  cells  and,  evidently,  are  the  occasion  of  the 
diminished  transparency.  The  parenchyma  of  the  pulp,  also, 
shows  a  similar  fatty  degeneration,  though  to  a  less  degree. 
In  some  parts,  the  fat-globules  form  chain-like  or  fusiform  aggre- 
gations and  follow  the  course  of  the  vessels  and  nerves;  in 
others,  the  minute  fat-molecules  are  scattered  in  the  interstitial 
connective  tissue  Avhich  may  be  cleared  up  by  the  addition  of 
acetic  acid  or  carbonate  of  soda.  In  consequence  of  the  abun- 
dance and  ready  accessibility  of  the  nerves  in  the  pulps  and  their 
roots,  it  is  quite  easy  to  demonstrate  the  granular,  fattv  meta- 
morphosis of  the  nerve-tubes  which  are  uniformly  thickened 
without  any  varicous  enlargements  (Atlas,  Fig.  47''').  It  cannot 
be  asserted,  however,  notwithstanding  the  existence  of  the  latter 
evidences  of  necrobiosis,  that  the  sensibility  of  such  nerves  is 
entirely  destroyed,  because  the  axis-cylinder  may  still  be  pre- 
served, though  the  nerve  medulla  has  undergone  a  molecular 
degeneration,  and  still  may  be  capable  of  performing  its  func- 
tions, though  its  conductibility  be  reduced  to  quite  a  low  degree. 
On  the  other  hand,  it  is  impossible  to  assert  absolutely  that  the 
medulla  of  each  and  every  nerve-tube  has  undergone  the  fatty 
metamorphosis. 

The  pulps  of  milk  teeth,  also,  while  the  latter  are  undergoing 
resorption  during  the  period  of  dedentition  and,  really,  are  se- 
nescent teeth,  sometimes  become  the  subjects  of  the  above  fatty 
degenerations  which  occur  in  the  same  manner  and  form  as  with 
the  subsequent  teeth. 

When  calcifications  occur,  the  coronal  pulp,  except  in  its  pe- 
ripheral portions,  is  i-endered  less  transparent  by  the  deposition 
of  roundish  calcareous  grains  within  its  parenchyma  which  con- 
veys a  gritty  sensation  when  touched  with  a  needle,  and  becomes 


234  ATROPUIES. 

more  opaque  in  the  mass  as  the  calcification  progresses.  In  the 
pulps  of  the  roots,  the  appearances  are  still  more  striking;  the 
calcareous  particles,  generally,  are  more  completely  arranged  in 
them,  so  that,  in  some  cases,  they  become  as  stiff  as  a  wire.  In 
order  to  examine  calcifications  with  the  eye  alone,  or  with  the 
aid  of  a  lens,  it  is  best  to  remove  the  pulp  and  allow  it  to  dry, 
or  to  make  longitudinal  or  cross-sections  through  the  teeth  con- 
taining calcified  pulps.  The  chalky-Avhite  calcareous  portions 
are  rendered  much  more  distinct  in  the  dried  condition  (Atlas, 
Figs.  51  and  53). 

The  calcifications  or  cretefactions  form,  in  rare  cases,  a  quite 
large  coherent  mass,  as  is  the  case,  for  example,  upon  the  pleura 
or  in  atheromatous  arteries;  generally,  however,  they  are  pre- 
sented in  a  reticular  or  nodular  form.  The  cohesion  is  less 
than  might  be  expected,  even  in  those  cases  where  calcification 
of  the  pulp  is  very  extensive,  since  even  these  admit  of  separa- 
tion in  the  direction  of  the  organic  envelopes  which  inclose  the 
calcified  portions. 

Upon  minute  examination  the  calcareous  concretions  in  the 
coronal  pulp  appear  in  the  form  of  nodules,  of  various  sizes,  im- 
bedded in  a  mass  of  fine  connective  tissue  (Atlas,  Fig.  46),  the 
outer  surfaces  of  which,  especially  if  they  have  attained  con- 
siderable size,  present  a  very  delicate  netAVork  or  arborescence 
and,  sometimes,  cup-shaped  depressions  when  high  magnifying 
powers  are  employed  (Atlas,  Fig.  52).  If  the  calcareous  salts 
are  removed  by  means  of  hydrochloric  acid,  there  remains  an 
ill-defined  filamentous  network,  composed  of  numerous  concen- 
tric layers,  which  bears  a  resemblance  to  coagulated  fibrin,  but 
cannot  be  regarded  as  such  in  a  decalcified  condition  since  there 
are  no  reasonable  grounds  for  such  a  view. 

The  small,  nodular,  calcareous  concretions  in  the  parenchyma, 
in  all  probability,  are  produced  in  one  of  two  ways :  either  by  a 
calcification  of  cells,  or  in  a  manner  analogous  to  that  in  which 
they  are  produced  in  the  urine  of  herbivorous  animals,  directly 
from  the  semi-fluid,  organic  mass  impregnated  with  calcareous 
salts,  without  the  intervention  of  cells.  As  soon  as  a  nucleus 
of  crystallization  is  established  in  the  form  of  a  firm  transparent 
grain  or  an  aggregation  of  minute  granules,  the  growth  proceeds, 


DENTAL    PULP. 


9?.l 


Fk.    7'1 


r 


(fn 


as  may  readily  be  demonstrated,  by  tbe  deposition  of  new  con- 
centric layers  around  the  grain  ;  frequently,  similar  grains  attach 
themselves  to  the  periphery  of  the  primary  grain  and  give  rise 
to  the  familiar  mulberry  forms  ;  contiguous  grains,  in  some  cases, 
coalesce  and  finally  produce  the  larger  nodular  concretions 
which  are  visible  to  the  naked  eye  in  the  form  of  spheroids  or 
spherical  segments,  arranged  in  clusters  of  a  few  or  aggregated 
into  a  large  mass.  Xow  and  then 
occur  calcareous  grains  of  a  round, 
oval,  or  dumb-bell  shape,  around 
which  are  deposited  very  sharply 
defined,  uniform,  cortical  layers, 
scarcely  0.001  of  a  millimetre 
apart  from  each  other,  which  per- 
sist after  the  removal  of  the  cal- 
careous salts.     (Fig.  79.) 

The  calcareous  nodules  present 
the  following  properties  :    a  strong 

refractive  power  ;  the  property  of  producing  double  refraction  ; 
if  treated  with  dilute  hydrochloric  acid,  decomposition  ensues, 
with  the  liberation  of  bubbles  of  gas  and  a  residue  of  an  organic 
basis-structure;  if  treated  with  dilute  sulphuric  acid,  numerous 
crystals  of  sulphate  of  lime  are  deposited. 

In  the  root-pulps,  sometimes,  also,  in  those  of  the  crown,  the 
concretions  assume  an  oblong,  cylindrical,  spicated,  or  spindle 
form  with  two  pointed  extremities  and  their  long  diameters  cor- 
responding with  that  of  the  radical  pulp.  They  are  located  in  the 
firm,  interstitial  bundles  of  connective  tissue,  the  sheaths  of  the 
bloodvessels  and  nerves.     In  the  tunica  adventitia,  especially,  of 


*  Fig.  79  shows  a  calcareous  deposit  in  the  central  portion  of  a  trans- 
versely divided  pulp  of  the  incisor  of  a  horse.  The  deposit  is  seen  in  the 
centre  and,  like  analogous  ones  which  occurred  in  other  places,  presents  a 
highly  refractive  power,  agranular  condition,  a  nucleus-like  structure  com- 
posed of  minute  spherical  concretions,  and  a  rounded  outline.  As  these 
agglomerations  were  located  near  the  central  portion  of  the  pulp,  cavities  of 
wide  bloodvessels,  transversely  divided  bundles  of  nerves  (a,  a),  and  capil- 
laries, interspersed  here  and  there,  occur  in  the  section.  Upon  the  periphery, 
connective-tissue  fibres  extending  from  the  margin  are  to  be  seen,  and 
roundish  connective-tissue  cells,  also,  are  visible.     Magnified  250  diameters. 


236  ATROPHIES. 

arteries,  concretions  of  this  description  are  fre(|uently  inter- 
spersed in  elongated  patciies  (Atlas,  Fig.  48).  The  narrow 
cylindrical  forms  occasionally  send  out  ramifications  in  the 
manner  of  fungus-threads,  and  these  forms,  probably,  are  pro- 
duced by  obliterated  thin  bloodvessels  which  have  undergone 
calcification.  The  trunks  of  the  nerves  not  infrequently  are 
so  concealed  within  the  calcareous  shells  that  a  careful  dissec- 
tion is  necessary  in  order  to  bring  them  into  view,  and  the 
nerve-medulla  of  the  tubes  frequently  degenerates  into  a  rigid 
highly  refractive  mass  which  does  not  completely  fill  the  cavity 
of  the  tubes  (Atlas,  Fig.  47^) ;  the  interstitial  connective  tissue 
of  the  trunks  is  reduced  to  membraniform,  more  or  less  friable 
lamellae.  The  bloodvessels  are  obliterated  and,  except  here  and 
there  where  they  are  filled  with  necrotic  blood,  are  generally 
empty  and  collapsed.  Nothing  is  left  of  the  dentinal  cells  but 
a  scanty  residue  when  the  calcification  is  very  extensive. 

Cases  occur  less  frequently  Avhere  the  walls  of  the  blood- 
vessels, especially  in  the  bodies  of  the  pulps,  undergo  quite  ex- 
tensive calcification,  so  that  the  vessels  of  medium  calibre,  to- 
gether with  their  branches  or  anastomotic  loops,  are  inclosed  in 
calcareous  envelopes  (Atlas,  Fig.  49),  which  give  to  the  vessels 
a  rigid  appearance,  a  brittle  character  and  a  rough  exterior. 
Here  and  there,  the  inner  coats  of  the  vessels  are  seen  to  project 
from  out  the  calcareous  cavity,  which  fact  serves  to  indicate 
that  the  tunica  adventitia  of  the  vessels  is  the  true  seat  of  the 
latter  calcareous  incrustation.  Occasionally  flattened,  quite 
large,  reticulated  concretions  are  met  Avith,  the  marginal  por- 
tions of  which  may  present  evidences  of  resorption  (Atlas,  Fig. 
52).  A  combination  of  net-like  calcareous  plates  with  a  rarefied 
dentinal  new-formation  also  occurs. 

The  frequent  occurrence  of  calcifications  of  the  pulp  is  not 
confined  merely  to  old  age  and  to  the  period  of  the  resorption 
of  the  roots  of  the  milk  teeth,  but  it  occurs  quite  early  in  many 
teeth,  independent  of  caries.  The  larger  calcareous  grains  must 
not  be  confounded  with  the  smaller  dentinal  new-formations.  The 
latter,  generally,  consist  of  a  compact,  yellowish,  transparent 
mass,  with  a  more  or  less  nodulated  surface  and  located  beneath 
the  superficial  layer  of  the  pulp  or  united  with  the  dentine,  and 


DENTAL    PULP.  237 

containing  dentinal  canals,  ^vhich,  however,  are  rarefied.  It  is 
a  fact  of  considerable  interest,  in  a  clinical  point  of  view,  that  sen- 
sations of  pain  are  not  necessarily  engendered,  notwithstanding 
the  very  abundant  calcareous  deposits  in  the  interstitial  connec- 
tive tissue  of  the  nerves.  Under  certain  special  conditions,  how- 
ever, which  we  cannot  explain  and  are  difficult  to  determine,  the 
calcareous  agglomerations  probably  do  excite  a  painful  irritation. 

Colloid  deposits  are  entirely  absent  in  many  cases  of  atrophic 
pulps,  while  in  others  they  are  present  in  abundance.  They 
present  the  familiar  globular  formations  which  refract  the  light 
like  opaque  glass,  and  are  unaffected  by  dilute  acids;  they  lie 
among  the  fibres  of  connective  tissue;  frequently  are  attached 
to  the  tunica  adventitia  of  the  bloodvessels,  or  are  adherent, 
Avithin  the  cavities  of  the  latter,  to  the  inner  coats  and,  also,  are 
imbedded  within  the  nerve-tubes.  When  the  colloid  masses  are 
abundant  and  of  small  dimensions,  with  the  exception  of  their 
glassy  aspect,  they  correspond  somewhat  Avith  connective-tissue 
cells  or  their  nuclei,  at  least  with  respect  to  their  size,  shape, 
and  arrangement,  and,  probably,  are  the  products  of  a  colloid 
metamorphosis  of  these  elem-ents.  The  smooth,  firm,  trans- 
parent bodies  which  occur  singly,  in  clusters,  or  are  fused 
together  into  a  glue-like  mass,  and  fill,  more  or  less,  the  cavity 
of  the  bloodvessel  (Atlas,  Fig.  50),  are  identical  with  the  mi- 
nute, shining  grains  observed  in  the  necrotic  blood,  which  are 
colloid  masses  formed  by  a  transformation  of  the  globulin  of  the 
blood-corpuscles  in  the  interior  of  the  vessel.  The  different 
steps  in  this  process  of  the  transition  of  the  red  blood-corpuscles 
Into  colloid  masses  may,  indeed,  be  traced  in  suitable  cases. 

The  7iet-Uke  atrophy  or  perversion  of  the  pulp  is  a  \q\^  in- 
teresting form,  in  a  histological  point  of  view.  Pulps  of  this 
description  are  recognizable  with  the  naked  eye,  by  their  flat- 
tened, shrivelled  appearance  and  finely  indented  outer  surfaces 
which,  otherwise,  are  smooth.  Their  color  is  darker,  gray-yel- 
low or  reddish-brown,  according  as  they  contain  a  smaller  or 
larger  amount  of  necrotic  blood  which  produces,  also,  indistinct, 
generally  rust-brown  spots.  Further,  they  have  a  dry  appear- 
ance, are  brittle,  and  of  about  the  consistence  of  parchment. 
The  action  of  acetic  acid,  by  means  of  which  the  connective-tis- 


238  ATROPHIES. 

sue  substances  swell  up  and  become  clear,  is  reduced  to  a  mini- 
mum. The  pulp  may  become  so  diminished  in  thickness  that  it 
is  as  thin  and  translucent  as  tissue-paper. 

The  diagnosis  of  net-like  atrophy  cannot,  however,  be  made 
with  the  unaided  eye  in  cases  where  it  is  not  so  pi'onounced  as 
in  the  above  description,  or  is  confined  to  narrow  limits.  A 
magnif^'ing  power  of  ten  to  twenty  diameters  is  suflficient  to  give 
quite  a  definite  idea,  where  it  is  desired  to  observe,  principally, 
the  network  upon  the  outer  surface  and  papilliform  pro- 
cesses which  are  located  at  uniform  intervals  from  each  other 
upon  the  marginal  portions  (Atlas,  Figs.  40  and  46).  The  dif- 
ferent colors  produced  by  the  blood,  and  the  dilatations  of  the 
vessels,  may,  also,  be  seen  very  well  with  the  same  magnifying 
power. 

If  now  one  investigates  more  closely  pulps  of  this  descrip- 
tion, beginning  with  the  dentinal  cells,  the  different  phases  of 
the  net-like  degeneration  must  be  taken  into  consideration.  In 
the  less  advanced  cases,  tolerably  well-preserved  dentinal  cells, 
groups  of  them  at  least,  are  met  with;  as  the  process  continues, 
they  fade  away  and  become  unrecognizable,  so  that  nothing  is 
left  of  them,  in  quite  large  tracts,  but  a  scanty  residue,  consist- 
ing of  short  filaments  extending  from  a  diaphanous,  membrani- 
form  substance  and  penetrating  the  dentinal  tubules.  The  bodies 
of  the  dentinal  cells,  consequently,  have  disappeared  entirely. 
If  such  a  wasted  group  of  dentinal  cells  be  examined  from  the 
surface,  it  presents  the  appearance  of  a  diaphanous  membrane 
perforated  like  a  sieve,  and  is  suggestive  of  a  cross-section  of  den- 
tinal tubules  (Atlas,  Figs.  42  and  44). 

The  anatomy  of  the  pulp,  which  has  been  considered  in  a  pre- 
ceding section,  is  to  be  taken  into  account  in  connection  with 
the  development  of  net-like  atrophy;  there  occurs,  namely,  a 
withering  of  the  reticulated  connective-tissue  cells  and,  also,  of 
the  peripheral  bloodvessels  and  nerves.  The  process  may  be 
traced  out  in  a  series  of  cases.  The  netwoi'k,  which  remains 
as  a  final  product  and  maintains  throughout  essentially  the 
same  character,  is  made  up  either  of  small  meshes  and  disposed 
in  numerous  layers,  or  of  larger  meshes,  and,  sometimes,  in  a 
single  layer.     Occasionally,  very  brilliant  nuclei  may  still   be 


DENTAL    PULP.  239 

recognized  at  the  points  of  junction  of  the  trabecule;  in  more 
advanced  cases,  however,  or  elsewhere  in  the  same  pulp,  they 
have  disappeared.  The  resisting,  rigid  trabeculse  have  a  yel- 
lowish color,  with  transmitted  light,  a  high  refractive  power, 
and  give  off  processes  which  penetrate  the  delicate  membrani- 
form,  intermediate  substance  that  fills  up  the  meshes.  The  mar- 
ginal portions  of  the  network  upon  the  periphery  of  the  pulp 
display  to  the  best  advantage  the  membraniform  nature  of  the 
intermediate  substance.  • 

The  anomalies  which  are  produced  in  the  bloodvessels,  in  con- 
nection with  net-like  atrophy,  are  very  characteristic.  In  the 
pulp  of  teeth  with  single  roots,  the  vessels  of  wider  calibre  not 
infrequently  attain  a  transverse  diameter  of  0.2  of  a  millimetre, 
and  even  are  larger;  usually  they  are  entirely  empty,  pursue 
an  undulatory  course  (Atlas,  Fig.  40)  and  their  walls  no  longer 
present  their  proper  arterial  or  venous  character,  those  of  the 
veins  consisting  merely  of  a  delicate  membrane  containing  barely 
discernible,  shrivelled  nuclei.  In  the  smaller  vessels,  varicosities, 
lateral  pouch-like  dilatations,  or  bud-like  offshoots  are  frequently 
met  with  (Atlas,  Fig.  45).  Very  often,  also,  contractions  of  the 
larger  vessels  and  strictures  of  the  smaller  ones  are  produced 
by  the  connective-tissue  trabeculee,  which  give  rise  to  various, 
more  or  less,  sinuous  forms.  In  other  places,  coils  of  the  ves- 
sels prevail.  They  contain  only  small  clots  of  blood  at  inter- 
vals. It  is  worthy  of  remark,  in  reference  to  these  orange-col- 
ored, rigid  columns  that  form  a  homogeneous  mass,  that  they 
present  at  one  end  a  concavity  in  the  form  of  a  meniscus,  a  con- 
dition Avhich  may  be  explained  by  the  adhesion  of  the  glutinous 
blood  to  the  wall  of  the  vessel  at  the  period  of  stasis  (Atlas,  Figs. 
43  and  44).  Usually  these  are  combined  with  products, of  meta- 
morphosed blood  in  the  form  of  molecular  precipitates,  fatty- 
acid  crystals,  plates  of  cholesterin,  &c.;  not  infrequently  the 
reticulated  tissue  has  become  tinged  with  blood  from  previous 
extravasations.  Here  and  there  the  red  corpuscles  may  still  be 
recognized,  deprived  of  their  coloring  matter,  necrotic,  and  an- 
gular in  consequence  of  their  mutual  pressure  one  against  the 
other. 

The  nerve-tubes  present,  very  distinctly,  the  atrophic  charac- 


240  ATROPHIES. 

tcr  which  has  been  described  above,  and  in  transparent  portions 
it  may  be  traced  without  any  previous  preparation,  by  their  no- 
tably flattened,  as  it  were,  mummified  condition. 

Net-like  atrophy  occurs  as  an  independent  involution  of  the 
tissues,  which,  apparently,  is  unattended  with  pain,  runs  a  chronic 
course  and  aiFects,  chiefly,  the  much  worn  teeth  of  old  persons, 
but,  also,  the  milk  teeth  at  the  period  of  shedding  the  teeth  and, 
more  particularly,  those  which  have  but  a  single  root. 

It  arises  from  nutritive  disturbances  which  are  induced,  pri- 
marily, by  varicous  expansions  and  spiral  curvations  of  the  ves- 
sels which  are  succeeded  by  stasis  and  efl"usion  of  the  blood.  The 
capillary  system  becomes  entirely  obliterated,  and  the  connective 
tissue,  which  serves  as  a  stay  or  support  for  the  nerves  and 
bloodvessels,  likcAvise  shrivels  up.  Nutrition  and  sensibility  are 
completely  arrested.  The  explanation  of  the  more  frequent  oc- 
currence of  general  atrophy  in  the  pulps  than  in  other  organs 
may,  perhaps,  be  found  in  their  diminutiveness,  in  the  compara- 
tively poAverful  pressure  to  which  the  worn  away  crowns  are 
subjected  in  mastication,  and  in  the  diminished  elasticity  of  the 
dentine  in  old  age. 

Sclerosis  belongs  to  the  rare  aff"ections  of  the  pulps.  Tense, 
cord-like  bundles  of  connective  tissue  interlace  in  the  very  tena- 
cious, resisting  bodies  of  the  pulps,  forming  sharp  angles  with 
each  other,  and  between  them  minute  fat-granules,  also,  occur. 
As  the  metamorphosis  advances,  the  bundles  of  nerves  waste 
away. 

The  difl"erent  processes  which  have  been  described  as  occur- 
ring in  the  retrograde  metamorphosis  of  the  dental  pulp,  some- 
times are  combined,  so  that  fatty  degeneration  occurs  with  cal- 
cification, colloid  deposits  with  sclerosis,  net-like  atrophy  with 
calcification  and  colloid  deposits.  Fatty  degeneration  and  net- 
like metamorphosis  very  rarely  are  combined.*  Atrophic  pulps 
may  even  become  the  subject  of  an  inflammatory  aff"ection,  in 
case  the  atrophy  has  not  advanced  too  far.  For  instance,  now 
and  then  a  marked  net-like  atrophy  is  complicated  with  a  puru- 
lent infiltration  into  the  superficial  portion  of  the  pulp,  from 

*  Hohl:  Deutsche  Viertelj.  f.  Zahnheilkunde,  18G6. 


DENTAL    PULP.  241 

caries  of  the  crown ;  partial  gangrene,  even,  may  ensue  in  an 
atrophic  pulp.  New-formations  of  dentine  are  frequently  the 
forerunners  of  the  atrophic  process. 

Adhesions  of  the  jjidp  to  the  internal  surface  of  the  dentine 
occur.  The  tAvo  structures  become  intimately  united,  so  that, 
instead  of  admitting  of  ready  and  complete  separation,  as  was 
the  case  originally,  they  become  united  by  a  delicate,  transparent 
membrane  which,  even  with  the  most  extreme  care,  is  easily 
torn  and  remains  adherent,  in  patches,  to  the  dentine.  Such 
adhesions  occur  more  often  in  the  pulp-cavity  than  in  the 
canal  ;  are  limited  usually  to  a  quite  small  portion  and  are, 
most  frequently,  the  concomitants  of  the  net-like  atrophy  and 
chronic  wasting  of  the  pulp,  in  conjunction  with  caries.  It  may 
be  observed  in  this  connection,  that  when  such  agglutinations 
take  place  between  the  pulp  and  the  dentine,  the  surface  of  the 
latter  not  infrequently  has  a  rough'  appearance,  being  marked 
with  numerous  elevations  and  depressions.  In  a  case  of  scle- 
I'osis  of  the  pulp  of  a  canine,  the  apex  of  the  pulp  was  attached 
to  the  internal  surface  of  the  dentine  by  means  of  a  cord-like 
band  which  stretched  between  the  dentine  and  apex  of  the  root. 

The  pigment  deposits  in  atrophic  pulps,  varying  according  to 
their  mode  of  origin,  form  dirty-yelloAv,  reddish-yellow,  brown- 
red,  or  dark-brown  spots.  Care  must  be  taken,  in  particular 
cases,  not  to  regard  the  deposits  of  pigment  as  a  direct  element 
of  the  atrophic  process,  since  they  belong  mucli  more  to  an 
accessory  pathological  process.  Thus,  circumscribed  or  diffused 
extravasations  of  blood  occur  in  conjunction  with  different  forms 
of  atrophy  and  various  transformations  of  color  ensue,  ac- 
companied by  the  precipitation  of  numerous  crystals  of  h^ma- 
toidin,  just  as  in  other  organs,  a  subject  which  was  considered 
in  the  section  upon  inflammatory  affections  of  the  pulp. 

The  highest  grade  of  atrophy  is  displayed  in  the  degeneration 
of  the  pxilp  into  a  soft,  greasy  mass,  unaccompanied  by  the  odor 
of  decomposition  ;  it  is  never  a  primary  affection,  but  is  the 
result  of  a  previous  inflammatory  process.  The  mass  is  com- 
posed merely  of  a  dirty  brownish-yellow  detritus,  or  traces  of 
a  fibrous  structure,  together  with  clusters  of  stellate  fatty- 
acid  crystals,  may  also  be  identified.     A  tooth,  which  has  been 

16 


242  ATiiopniEs. 

the  su1)ject  of  a  total  decay  of  this  description,  is  no  longer 
firmly  attached  within  its  alveolus. 

A  notable  dimmution  in  the  size  of  the  pulp-cavity  and  dental- 
canal  occurs  in  advanced  age.  The  size  diminishes  in  various 
ways,  but  is  effected,  always,  by  the  continued  deposition  of  new 
dentinal  layers.  The  pulp-cavities  of  the  lower  molars,  especi- 
ally, are  reduced,  not  infrequently,  to  a  transverse  fissure  with 
narrow,  short  prolongations  extending  towards  the  masticating 
surface.  In  teeth  with  a  single  root,  the  pulp-cavity  is  not  di- 
minished so  much  in  length,  as  it  is  contracted  from  side  to 
side.  The  internal  dentinal  surface  is  marked,  frequently,  with 
tiny,  resisting,  rounded  excrescences.  In  old  age,  also,  the 
growth  of  the  dentine  is  disproportionately  active  within  a 
limited  area,  and  is  abnormal  in  character,  in  other  words,  new- 
formations  of  dentine  occur.*  The  root-canals  become  more 
narrow,  and  the  apertures  at  the  extremities  of  the  roots  not 
infrequently  become  indiscernible. 

Senile  Dentine  has,  generally,  a  yellowish  coZor,  with,  some- 
times, a  sprinkling  of  brownish  or  dirty  gray.  Its  fragility 
and  brittleness  may  become  so  great  that  if  such  teeth  are  com- 
pressed sufficiently  in  a  vice,  they  may  easily  be  cracked  in 
definite  directions,  and  teeth  with  a  single  root  may  be  divided 
into  two  symmetrical  portions.  Another  physical  peculiarity  is 
presented  in  the  increased  translucency  of  certain  portions,  the 
so-called  horny  character. 

As  is  well  known,  the  latter  is  met  with  most  frequently  at 
the  extremities  of  the  roots,  but  may  be  continued,  in  old,  much 
worn  teeth,  as  far  as  the  necks,  indeed,  in  places,  even  into  the 
crowns.  It  is  distinguished,  also,  by  a  yellowish  hue  which, 
upon  the  surface  of  cross-sections,  is  interrupted  by  the  chalky- 
white  tracings  of  the  dentinal  tubules  filled  with  air,  and,  not 
infrequently,  presents  an  infundibuliform  prolongation  towards 
the  enamel  layer.  In  the  peripheral  zone  of  such  diaphanous 
dentine,  where  the  numerous,  delicate  ramifications  of  the  den- 
tinal canals  occur,  a  faint  tinge  of  gray  becomes  perceptible. 

By  means  of  thin  sections,  it  may  readily  be  demonstrated 

*    Vide  the  section  upon  Dentinal  New-formations. 


SENILE    DENTINE.  243 

that  the  increased  translucency  of  the  dentine  is  dependent 
upon  the  absence  of  air  in  the  dentinal  tubules,  and  that  the 
more  opaque  portions,  which  usually  correspond  exactly  with 
the  course  of  the  tubules  and  are  white  with  reflected  light,  owe 
these  peculiarities  to  the  air  contained  in  the  tubules. 

The  question  at  once  arises  :  Do  the  dentinal  tubules,  or 
more  strictly  speaking,  do  the  processes  of  the  dentinal  cells, 
generally,  still  persist  in  the  diaphanous  portions  of  the  den- 
tine ?  In  order  to  determine  this  point,  thin  cross-sections 
were  prepared  from  translucent  portions  of  the  extremities  of 
roots,  and  by  means  of  heated,  dilute,  hydrochloric  acid,  the 
processes  in  question  were  brought  into  view.  In  these  experi- 
ments, no  essential  difference  could  be  discovered  between  the 
translucent  and  less  diaphanous  portions  of  the  dentine. 

In  order  to  show  whether  processes  of  the  dentinal  cells  of 
such  horny  roots  still  retain  the  property  of  imbibition,  thin 
cross-sections  of  the  latter  in  a  dried  condition  were  heated 
slightly  and  placed  in  a  strong,  ammoniacal,  carmine  solution, 
and  afterwards  treated  with  dilute  acetic  acid.  The  tinged  sec- 
tions were  then  allowed  to  dry,  or  were  treated  with  absolute 
alcohol,  and  placed  in  Canada  balsam,  when  it  was  found  that 
the  coloring  matter  had  penetrated  even  to  the  finest  ramifica- 
tions of  the  processes  of  the  dentinal  cells. 

Since,  then,  it  is  proved  beyond  a  doubt,  that  the  processes  of 
the  dentinal  cells  do  exist  in  the  translucent  portions  of  senile 
dentine,  and  that  they  still  retain  the  property  of  imbibition,  it 
may  be  assumed,  wuth  a  certain  degree  of  plausibility,  at  least, 
that  these  processes,  as  well  as  other  tissues,  in  the  decay  of 
advanced  age  have  lost,  more  or  less,  their  distensibility  ;  that 
their  central  vitreous  substance  has  disappeared,*  and  that,  to- 
gether with  the  investing  walls  of  the  dentinal  tubules,  they 
have  become  closed  in  such  a  manner  that  the  entrance  of  at- 
mospheric air  is  no  longer  possible. 

Still  another  point  may  be  taken  into  consideration,  as  to 
whether  or  not  a  change  is  induced  in  the  aggregation  of  the 
basis-substance,  which  may  contribute  to  the  production  of  the 

*  Compare  p.  44. 


244  ATROPHIES. 

traiislucencj.  Premising  that  the  so-called  dental  cartilage 
gradually  loses  its  succulency,  then  the  inorganic  particles,  the 
calcareous  salts,  which  are  organically  combined  with  the  car- 
tilage, become  more  closely  approximated,  and  their  relative 
positions  with  respect  to  each  other  become  altered.  By  this 
process,  the  general  dimensions  of  the  tooth  will  be  lessened, 
and  its  physical  properties  will  suffer  a  perceptible  alteration. 
The  subject  of  the  resorption  of  senile  dentine  will  be  consid- 
ered farther  on  in  connection  with  that  of  the  cement. 

Cement, — The  thickening  of  the  cemeiit  incident  to  old  age 
is  analogous  to  the  continued  formation  of  dentinal  cells  upon 
the  internal  surface  of  the  dentine.  As  is  well  known,  thick- 
ened cement  is  a  very  frequent  occurrence ;  upon  teeth  with  a 
single  root,  it  is  confined  to  the  extremity  and  increases  rapidly 
towards  the  apex,  while  upon  teeth  with  multiple  roots,  it  ex- 
tends not  infrequently  towards  the  neck  of  the  tooth  as  far  as 
the  junction  of  the  roots  and  forms,  therefore,  a  uniform  cov- 
ering over  a  considerable  portion  ;  contemporaneous  with  this 
thickening  process  occurs  a  resorption  of  the  dental  socket, 
and,  in  this  respect,  an  analogy  with  bone  is  presented,  in  which, 
also,  resorption  and  the  continued  development  of  osseous  tissue 
may  be  concurrent  processes.  For  instance,  upon  the  surfaces 
of  the  flat  bones  of  the  skull,  an  expansion  of  the  openings  of 
the  Haversian  canals  and  distinct  excavations  from  resorption 
are  met  with,  and,  at  the  same  time,  a  progressive  sj^nosteosis 
in  the  vicinity  of  the  sutures.  Ossification  of  the  synchon- 
droses, along  with  the  resorption  of  other  portions  of  the  bone, 
is  a  familiar  occurrence  in  advanced  age. 

The  new  layers  of  cement  are  not  always  deposited  in  a  con- 
centric manner  about  the  older  ones,  but  frequently  form  more 
or  less  acute  and  even  right  angles  with  the  latter.  The  symmet- 
rical development  of  the  bone-corpuscles  does  not  obtain  every- 
where, since  the  striated,  frequently  turbid,  intercorpuscular 
substance  acquires  such  a  preponderance  in  some  localities  that 
the  bone-corpuscles  become  dispersed  at  wide  intervals  from 
each  other.  In  other  places,  the  bone-corpuscles  are  closely  ap- 
proximated, sometimes  fused  together,  as  it  were,  so  as  to  form 
a  jagged,  quite  large  cavity  which  is  filled  with  calcareous  salts. 


RESORPTION    OF    SENILE    DENTINE    AND    CEMENT.       245 

The  necrobiotic  portions  are  of  interest  and  may  be  traced  for  a 
considerable  distance  in  layers  of  the  thickened  cement  by  the 
very  turbid,  dirty-yellow  or  yellowish-brown  discolorations. 
Apparently,  the  intercorpuscular  substance  degenerates  into 
granular,  amorphous  calcareous  salts,  amongst  which  the  bone- 
corpuscles  may  still  be  recognized  here  and  there.  The  cement 
of  the  teeth  of  old,  larger  mammals,  is  particularly  instructive 
upon  this  point. 

The  thickened  senile  cement  is  traversed,  usually,  by  vascular 
canals  which  communicate  with  the  vessels  of  the  root-mem- 
brane, enter  the  cement,  as  a  rule,  in  directions  perpendicular 
to  the  surface  of  contact  with  the  latter  membrane,  branch 
dichotomously  and  anastomose  with  each  other  by  means  of  their 
branches.  They  are  prolonged  in  their  course  as  far  as  the 
dentine,  indeed,  under  certain  circumstances,  even  into  the 
latter;  their  cavities  are  comparatively  wide  and,  frequently, 
obliterated  by  amorphous,  calcareous  salts  (comp.  p.  53.) 

Resorption  of  Senile  Dentine  and  Cement. — If  we  com- 
pare the  periphery  of  the  dentine  of  a  series  of  teeth  from  old 
persons,  even  with  the  naked  eye  a  zone  will  be  perceived,  cor- 
responding to  the  globular  layer  between  the  dentine  and  cement 
and  appearing  quite  opaque  with  transmitted  light  and  very 
white  with  reflected  light.  The  interglobular  spaces,  replete 
with  amorphous  calcareous  salts,  have  increased  in  extent  and 
appear  as  cavities  with  irregularly  indented  outlines  and  fissure- 
like channels  filled  Avith  calcareous  salts.  These  cavities  and 
channels  not  unfrequently  penetrate  into  the  substance  of  the 
dentine,  where  their  dentiform  prolongations  are  in  direct  con- 
nection with  the  dentinal  tubules.  Varicous,  spindle-shaped  dila- 
tations in  the  course  of  the  dentinal  tubules  are  met  with,  or 
opaque  cavities  with  three,  four  or  more  dentations  which  are 
clustered  in  varying  numbers  between  the  dentinal  tubules,  and 
must  not  be  confounded  with  bone-corpuscles.  In  very  rare 
cases,  the  dentine  is  studded,  quite  generally  or  almost  entirely, 
with  uniformly  distributed  cavities  filled  with  amorphous  cal- 
careous salts,  which  give  to  it  a  mottled  appearance.  This  con- 
dition may  be  explained  by  the  occurrence  of  resorption  of  the 
dentinal  substance  along   the   dentinal   tubules  as   a  result  of 


246  ATROPHIES. 

which  these  cavities  are  produced  which  become  filled  with 
amphorous  calcareous  salts. 

It  has  been  mentioned  above,  that  vascular  canals  occasionally 
penetrate  from  the  cement  into  the  peripheral  portions  of  the 
dentine,  where  they  may  be  traced  for  some  distance,  but  they 
become  obliterated  directly  by  the  deposition  of  calcareous 
grains  and,  occasionally,  are  surrounded  by  an  osteoid  substance. 

Excavations  from  resorption  do  not  make  their  appearance 
upon  the  periphery  of  the  dentine  until  the  contiguous  portions 
of  the  cement  have  undergone  complete  resorption. 

Cement  which  has  undergone  partial  resorption  frequently 
presents  an  appearance  that  is  observed  in  connection  with  re- 
sorption of  the  roots  of  the  milk  teeth.  While  the  familiar 
indentations  produced  by  resorption  are  making  their  appear- 
ance upon  the  periphery  of  the  cement,  sharply  defined,  lobu- 
lated  formations  of  osseous  substance  are  observed  in  the  zone 
adjacent  to  the  dentine,  which  not  infrequently  reach  some  dis- 
tance into  the  latter.  (Atlas,  Fig.  113.) 

The  peripheral  zone  of  the  dentine,  consequently,  undergoes 
resorption  in  various  ways,  namely,  by  an  increase  in  the  num- 
ber and  size  of  the  interglobular  spaces ;  by  an  extension  of  the 
resorption  process  from  the  cement  and  by  the  encroachment  of 
young  osseous  tissue. 

Enamel. — The  enamel  of  the  teeth  of  elderly  persons  acquires 
the  brittleness  of  glass,  is  cracked  quite  easily  when  subjected 
to  pressure,  and  presents  a  smooth  or  splintered  and,  also,  a 
conchoidal  fractured  surface.  Senile  enamel  is  distinguished 
by  a  yellowish  or  brownish-yellow  color  which  is  interspersed, 
sometimes,  with  dark-brown  spots.  The  latter  are  of  limited 
areas  and  pass  imperceptibly  into  the  lighter  layers;  they  are 
by  no  means  to  be  considered  as  indicative  of  commencing 
caries,  and  may  exist  for  years,  as  is  very  Avell  known,  without 
any  further  deterioration  of  the  teeth.  The  dark  discoloration 
may  be  present  at  intervals  throughout  the  entire  thickness  of 
the  enamel,  and  yet  the  continuity  of  the  latter  may  remain 
unimpaired ;  this  condition  has  its  analogy  in  the  occurrence  of 
deposits  of  pigment  in  other  organs  during  advanced  age.  A 
molecular  degeneration,  however,  also   occurs   in    the  enamel, 


SURFACES    PRODUCED    UPON    CROWNS    BY    ATTRITION.      24:7 

"wliicli  is  displayed,  even  to  the  naked  eye,  in  the  form  of  Avhite 
zones  or  spots;  it  is  associated  with  an  interruption  in  the  con- 
tinuity of  the  prisms  and  is  morphologically  identical  with  the 
imperfect  formation  of  enamel. 

The  enamel-membrane  of  senile  teeth,  as  much  of  it  as  still 
persists,  in  comparison  with  that  of  younger,  normal  teeth,  is 
thicker  frequently,  often  contains  deposits  of  dark-yellow,  gra}'- 
brown  or  deep-brown,  and  from  this  to  a  black-brown  pigment, 
or  presents  a  molecular  cloudiness,  and  is  occupied  by  a  mass  of 
drops  which  have  the  shining  appearance  of  fat  and  may  be 
removed  with  ether.  Sometimes  this  membrane  presents  tear- 
like, firm,  colloid-like  bodies  with  broad  bases,  the.  convex  sur- 
faces of  which  project  at  the  points  where  the  membrane  is 
reflected  upon  itself;  they  are  distinguished  by  a  faint  lustre,  a 
rounded  exterior,  and  are  irregularly  disposed,  being  isolated  in 
some  parts  and  grouped  together  in  others.  (Atlas,  Fig.  82.) 

Surfaces  produced  upon  the  Crowns  by  Attrition. — 
These  are  found  upon  the  masticating  surfaces  and  at  the  parts 
where  adjacent  crowns  come  into  contact  with  each  other.  In 
the  former  case,  they  are  produced  by  the  trituration  of  food. 
Hence  the  nature  of  the  latter,  the  manner  in  which  it  is  pre- 
pared, its  uniformity  or  variety,  will  have  an  important  influence 
in  the  production  of  these  surfaces.  This,  to  be  sure,  is  a  diffi- 
cult matter  to  determine  in  the  case  of  man,  but  with  animals 
which  receive  special  care  and  attention,  with  stud  horses,  for 
example,  it  is  a  matter  of  recognized  importance.  The  more 
dry,  and  tougher  the  fodder,  the  longer  and  more  forcible  will 
be  the  process  of  mastication,  and  the  sooner  will  corresponding- 
abrasion  of  the  teeth  ensue.* 

*  John  K.  Mummerj^  (Trans,  of  the  Odont.  Soc.  of  Great  Britain,  Jiew 
series,  vol.  ii)  instituted  very  extended  investigations  to  show  that  tliere  is 
a  notable  difference  with  respect  to  the  form  in  which,  and  the  means  by 
which,  the  teeth  become  worn  away.  Nations,  like  the  Egyptians,  and  the 
Indians  of  the  northwest  coast  of  America,  take  but  little  pains  in  the 
preparation  of  their  food  which,  consequently,  often  contains  sand,  so  that, 
usually,  tiieir  teeth  are  worn  away  evenly.  If  the  food  consists  of  hard  seeds, 
roots,  or  tough  meat,  then  the  surfaces  of  the  first  molars  are  found  to  be 
most  worn  away,  upon  the  lingual  side  in  the  upper  jaw  and  upon  the  labial 
eide  in  the  lower  jaw.     "With  those  who  subsist  upon  an  abundance  of  highly 


248  ATROPHIES. 

Generally  speaking,  tlio  surfaces  become  worn  away  upon  the 
tubercles  and  edges  at  the  points  of  contact  between  the  upper 
and  lower  teeth,  where  they  glide  upon  each  other  in  certain 
directions  during  the  act  of  chewing.  Projecting  crowns  are 
worn  down  very  soon  ;  if  their  axes  are  nearly  perpendicular, 
they  are  worn  away  in  a  more  or  less  horizontal  direction ; 
those  obliquely  situated  are  Avorn  in  an  oblique  direction,  and 
those  having  no  crowns  opposite  them  are  not  subjected  to  fric- 
tion. Since  the  crowns,  and  particularly  the  incisive  edges  and 
tubercles  of  the  teeth  of  the  upper  and  lower  jaw,  respectively, 
are  inclined  towards  one  another,  and  the  act  of  chewing  is  per- 
formed in  definite  curves,  the  facets,  produced  by  attrition,  are 
observed,  also,  to  assume  an  oblique  disposition,  those  of  the  lower 
teeth  being  located  upon  the  facial  si<le,  and  those  of  the  upper 
teeth  upon  the  lingual  side.  The  approximation  of  the  planes 
of  the  facets  to  the  horizontal  direction  depends  upon  the  angles 
of  inclination  of  the  opposing  coronal  axes. 

When  the  entire  thickness  of  the  enamel  has  been  worn  away, 
the  summit  of  the  dentine,  at  the  corresponding  point,  becomes 
similarly  involved,  so  that  the  surface  of  attrition  presents  an 
island  of  dentine  surrounded  by  enamel.  If  the  crown  is  worn 
down  nearly  to  the  neck  of  the  tooth,  a  greater  portion  of  the 
dentine  becomes  exposed  and  presents  a  polished  surface  like 
that  of  a  mirror,  not  infrequently  becomes  excavated  as  the 
process  progresses,  has  a  3'ellowish  or  brownish-yellow  color 
and,  at  last,  forms  merely  a  thin  covering  over  the  dental  pulp. 
The  enamel  persists  only  upon  the  remaining  lateral  portions. 
If  the  abrasion  of  the  thin  dentinal  covering  is  continued,  the 
atrophic  dental  pulp,  which  generally  has  been  rendered  firm  by 
a  dentinal  new-formation  or  has  undergone  partial  calcification, 
becomes  exposed  and  is  perceptible  in  the  centre  of  the  masti- 
cating surface  as  a  defined  body  surrounded  by  dentine.  If  a 
shrinking  of  the  alveolar  process  has  already  commenced,  then 

nitrogenous  food,  the  pulps  of  the  teeth  grsvdually  become  solidified  with  sec- 
ondary dentine  and  the  tooth  frequently  is  worn  away  as  far  as  the  neck 
without  the  occurrence  of  an  alveolar  abscess  ;  on  the  contrary,  in  cases  where 
there  is  a  defective  nourishment,  inflammations,  abscesses,  and  extensive  re- 
sorption of  the  alveoli  are  constantly  observed. 


SURFACES  PRODUCED  UPOX  CROWNS  BY  ATTRITION.  249 

the  entire  neck  of  the  tooth  will  become  worn  a^ay,  and  even 
the  contiguous  projecting  portions  of  the  roots  may  be  involved 
in  the  process. 

As  the  crowns  become  more  and  more  worn  away,  the  ser- 
pentine curve,  which  is  described  by  all  the  coronal  margins  in 
common,  gradually  disappears,  and  finally  the  dental  arches  of 
the  upper  and  lower  jaws  come  into  contact  by  means  of  broad 
surfaces,  and  the  lower  half  of  the  face  is  shortened. 

From  the  degree  to  which  the  teeth  are  worn  away,  a  probable 
conclusion  may  be  drawn  in  regard  to  the  age  of  an  individual. 
After  considerable  practice,  it  is  possible  to  determine  the  age 
within  at  least  five  years,  from  the  latter  and  accessory  data, 
as,  for  instance,  from  the  variations  in  the  color  of  the  teeth 
and  from  the  changes  presented  by  the  alveolar  borders,  &c. 
In  drawing  conclusions  of  this  kind,  however,  individual  peculi- 
arities must  also  be  taken  into  account.  The  time  required  for 
a  certain  amount  of  wear  depends  upon  the  hardness  or  density 
which  varies  in  different  teeth.  This  may  be  determined,  most 
satisfactorily'^,  in  regard  to  milk  teeth  which,  in  consequence  of 
their  slight  density,  present  evidences  of  attrition  in  a  compara- 
tively short  period.  Frequently,  also,  sets  of  teeth  are  found 
in  young  persons  which  are  comparatively  stronger  than  usual, 
and  such  teeth  are  but  little  worn  when  the  individuals  become 
advanced  in  age. 

With  animals  that  are  fed  upon  a  uniform  kind  of  food,  the 
teeth  become  worn  away  in  a  quite  constant  manner.  The  two 
Giichters,  father  and  son,  of  Hanover,*  investigated  this  point 
and  ascertained  that  the  amount  lost  by  attrition  upon  the  per- 
manent incisors  of  the  anterior  and  posterior  jaws  observed  a 
tolerably  constant  measurement,  namely,  a  line  annually.  The 
shape  of  the  surfaces  produced  by  attrition  of  the  incisors  cor- 
responds with  transverse  sections  of  the  latter,  and  are  roundish, 
triangular,  oblong,  &c.  Hence,  from  these  data  it  is  possible  to 
determine  the  age  of  a  horse  with  tolerable  accuracy  beyond  the 
period  of  dentition,  even  to  the  thirtieth  year.  As  the  horse 
grows  old,  and  the  uniform  abrasion  of  the  incisors  is  continued, 

*  Beurtheiliuiii-slehre  des  Pferdes. 


250  ATROPHIES. 

the  arches  formed  b}'  the  respective  sets  of  teeth  disappear,  and 
the  teeth  gradually  acquire  a  position  in  a  straight  line. 

In  entirely  normal  sets  of  human  teeth,  facets  from  attrition 
first  make  their  appearance  upon  the  incisors,  the  prominent 
blunt  points  upon  the  incisive  edges  of  ■which  disappear;  thej 
then  become  perceptible  upon  the  outer  portions  of  the  crowns 
of  the  first  and  second  molars  of  the  lower  jaw,  and  later  upon 
the  internal  coronal  borders  of  the  corresponding  teeth  of  the 
upper  jaw.  The  explanation  of  these  familiar  appearances  is  to 
be  found  in  the  position  of  the  teeth,  in  accordance  ■with  -which 
the  facial  coronal  borders  of  the  lower  molars  impinge  upon  the 
lingual  borders  of  the  npper  molars,  and  the  two  become  sub- 
jected to  friction,  in  the  vibratory  movements  of  mastication. 
In  this  way,  facets  are  produced  opposite  each  other  upon  the 
prominent  points  of  the  above-mentioned  coronal  borders;  these, 
at  first,  are  barely  a  millimetre  square,  but  as  the  process  con- 
tinues, they  increase  in  size,  and  the  prominence  of  their  edges 
gradually  becomes  lost ;  still  later,  quite  large  inclined  facets 
are  produced  which  involve  the  entire  outer  and  inner  sides  of 
the  crowns  respectively.  The  previously  sharp  borders  of  the 
molars  frequently  are  rounded,  with  scarcely  any  faceted  ap- 
pearance. The  wisdom  teeth,  on  account  of  their  late  and  often 
incomplete  advance  to  the  level  of  the  masticating  surfaces,  be- 
come worn  away  at  a  later  period  and  to  a  less  degree  than  the 
other  teeth. 

The  facial,  coronal  tubercles  of  the  bicuspids  of  the  lower  jaw 
are  -worn  away  obliquely  outwards  ;  the  lingual  tubercles,  small 
and  situated  at  a  much  lower  level,  are  not  involved  until  the 
former  are  almost  entirely  worn  away  and  the  dentine,  even,  has 
become  exposed  in  the  form  of  a  yellow  band.  Upon  both 
tubercles  of  the  upper  bicuspids,  facets  are  produced  which  are 
inclined  in  opposite  directions.  That  upon  the  facial  tubercle 
appears  first,  and  is  larger  than  the  other. 

The  lower  canines  present  two  obliquely-situated  facets  upon 
their  facial  surfaces,  one  of  which  is  directed  anteriorly,  and 
the  other  posteriorly.  As  the  process  continues,  the  tAvo  small 
facets  disappear  and  give  place  to  a  larger  one  directed  towards 
the  face,  in  the  centre  of  which  the  polished  dentine  becomes 


SURFACES  PRODUCED  UPON  CROWNS  BY  ATTRITION.  251 

perceptible  as  a  transverse  band.  The  upper  canines,  likewise, 
present  two  facets  Avliicli  meet  at  an  angle;  these,  however,  are 
located  upon  the  lingual  side  of  the  coronal  apex  ;  in  the  more 
advanced  stages,  a  larger  facet,  inclined  towards  the  tongue,  is 
met  with. 

Upon  the  lower  incisors,  the  facets  are  obliquely  situated, 
being  directed  from  the  coronal  edge  towards  the  face,  while 
those  upon  the  upper  teeth  are  directed  towards  the  tongue. 
In  advanced  stages  of  the  process,  the  dentine  is  exposed  and 
presents  the  appearance  of  a  transverse  yellow  band ;  a  quite 
opaque,  firm  portion  is  frequently  observed  in  the  centre  of  the 
latter,  which  Hunter,  long  ago,  and  Prochaska,  described  as  a 
commencing  hard  new-formation  which  is  to  serve  for  the  closure 
of  the  pulp-cavity  (comp.  Dentinal  New-formations). 

As  the  character  of  the  attrition  depends  upon  the  position 
of  the  two  opposing  teeth  in  the  upper  and  lower  jaw  respec- 
tively, and  anomalies  of  position  occur  very  frequently  and  in 
infinite  variety,  it  follows  that  the  surfaces  which  are  produced 
by  attrition  present  an  endless  variety.  With  very  prominent 
jaws,  these  facets  assume  an  oblique  direction  which  approxi- 
mates the  perpendicular.  With  an  upright  set  of  teeth,  in  which 
the  axes  of  the  dental  crowns  have  a  nearly  perpendicular  direc- 
tion from  above  downward,  the  facets  necessarily  assume  a 
horizontal  direction. 

With  asymmetrical  jaws,  where  the  masticating  surfaces  of 
the  two  sets  do  not  correspond  with  each  other,  chewing  is  con- 
fined to  one  side,  and  the  teeth  of  that  side  become  much  worn, 
and  in  a  very  oblique  direction.  The  teeth,  as  a  whole,  then 
acquire  a  distorted  arrangement,  and  give  rise  to  a  corresponding 
distortion  of  the  mouth. 

When  all  the  teeth  of  one  or  another  kind  are  w^anting,  for 
example,  all  the  upper  molars  on  the  right  side,  mastication  is 
performed  only  upon  the  left  side  posteriorly,  and  the  molars 
upon  the  latter  side  become  worn  down  obliquely  and  much 
earlier.  If  the  upper  molars  of  both  jaws  are  wanting,  masti- 
cation is  transferred  to  the  front  teeth  which  acquire  large, 
more  or  less  obliquely  or  horizontally-disposed  facets. 

When  a  tooth  is  lost,  the  opposite  one,  deprived  of  its  antago- 


252  ATROPHIES. 

nist  in  biting,  ceases  to  exercise  its  function  and  experiences  no 
more  wear  from  attrition.  The  tooth  Avhich  loses  the  support  of 
its  neighbor  upon  one  side,  as  will  be  noticed  later  in  connection 
with  the  subject  of  cicatrization  of  the  dental  sockets,  becomes 
inclined  towards  its  newly-acquired  neighbor,  and,  as  a  result  of 
this,  the  correspondence  between  the  crown  of  the  dislocated 
tooth  with  that  of  its  non-dislocated  opposite  is  destroyed.  If, 
for  example,  a  second  lower  molar  acquires  an  inclination  from 
behind  forwards,  subsequent  to  the  loss  of  the  first  molar,  then 
the  facet  from  attrition  upon  the  former  will  be  directed  obliquely 
backwards,  and  that  upon  the  second  upper  molar  obliquely 
forwards.  We  may,  also,  determine  the  position  of  its  opposite 
from  the  direction  and  size  of  the  facet  upon  a  tooth. 

The  dental  crowns,  also,  are  subjected  to  attrition  at  the  points 
where  they  come  into  contact  with  the  crowns  of  adjacent  teeth, 
a  familiar  fact  to  every  dentist.  The  frictional  surfaces  on  the 
crotvns,  produced  in  this  way,  are  described  by  A.  Zsigmondi* 
as  ^'■mterstitial.''  They  are  produced  by  the  movements  of  the 
teeth  in  their  sockets  during  mastication  and,  therefore,  can 
occur  only  when  adjacent  teeth  come  into  contact  with  each 
other.  Of  course,  the  wisdom  teeth  present  none  upon  their 
posterior  coronal  surfaces.  The  nature  of  the  contact  varies 
with  different  teeth  and,  therefore,  we  find  a  variety  in  the  shapes 
presented  by  the  frictional  surfaces ;  indeed  the  latter  neces- 
sarily change,  if  the  position  of  a  tooth  in  its  relation  to  that  of 
its  neighbor  is  altered  in  any  way.  With  reference  to  the  latter 
point,  Zsigmondi  makes  the  following  special  observations : 
"  The  frictional  surfaces  resulting  from  the  contact  of  the 
incisors  with  each  other,  and  with  the  canines  (corresponding 
with  the  thin  lateral  margins  of  the  former),  are  narrow,  longi- 
tudinally disposed,  and  more  or  less  oval  in  shape ;  where  the 
rounded  posterior  surfaces  of  the  canines  come  into  contact  with 
the  first  bicuspids,  they  are  roundish;  those  resulting  from 
friction  between  the  first  and  second  bicuspids  are  somewhat 
larger,  transversely  disposed,  and  more  or  less  oval  or  polygonal 
in  shape ;  finally,  those  from  friction  between  the  second  bicus- 

*  Vierteljalu-schr.  f.  Ztihnh.,  1865. 


SURFACES    PRODUCED    UPON    CROWNS    BY    ATTRITION.      253 

pids  and  first  molars  and,  also,  from  contact  of  the  molars  with 
each  other  (corresponding  to  the  broad  surfaces  of  contact  of 
the  latter),  are  considerably  larger  and  broader,  and,  like  the 
preceding  ones,  are  disposed  from  side  to  side  and  of  an  oval  or 
polygonal  shape." 

Wedge-shaped  defects  upon  the  facial  surfaces  of  the  necJcs  of 
teeth. — Sometimes,  though  rarely,  a  curious  breach  of  substance 
(Usur)  is  observed  upon  the  facial  aspect  of  the  neck,  particu- 
larly of  the  incisors  and  molars.  These  defects  are  bounded  by 
sharp  edges,  as  if  artificially  made  with  a  file  (Atlas,  Fig.  99), 
and  present  two  surfaces,  one  horizontal  and  the  other  inclined 
at  an  angle  of  45°.  The  wedge-shaped  depressions  are  one  to 
two  millimetres  in  depth,  their  edges  are  very  sharp,  their  sur- 
faces have  a  polished  appearance.  Persons,  upon  whose  teeth 
they  occur,  know  nothing  respecting  their  origin,  nor  have  den- 
tists, as  it  appears,  made  any  extended  investigations  with  ref- 
erence to  this  point.  Fox*  speaks  of  a  removal  of  the  enamel 
which  is  not  produced  by  caries.  This  affection,  he  says,  occurs 
upon  the  labial  surfaces  of  the  incisors  particularly,  which  ap- 
pear as  if  they  had  been  gnawed.  After  the  enamel  is  destroyed, 
a  portion  of  the  dentine  becomes  involved,  and  the  rest  acquires 
a  brownish  color,  is  highly  polished  in  appearance,  and  will  often 
remain  in  this  condition  for  a  number  of  years.  In  other  cases, 
he  observed  teeth  which  presented  an  appearance  as  if  a  small 
I'ound  file  had  been  applied  to  their  labial  surfaces,  in  close 
proximity  to  the  gums.  In  these  cases,  the  molars  participate 
in  the  disease.  He  states  that,  posssibly  the  saliva  may  have 
some  influence,  and  that  the  friction  of  the  lips,  also,  may  con- 
tribute to  the  removal  of  the  enamel. 

The  view,  that  these  cases  are  instances  of  healed  caries  of 
the  gum,  cannot  be  entertained,  as  the  defect  is  too  sharply  de- 
fined; nor  is  it  possible  to  detect  any  traces  of  previous  caries  of 
the  gum.  The  fact,  that  such  defects,  so  far  as  our  present  knowl- 
edge extends,  are  never  found  upon  the  lingual  surfaces  of  the 
neck,  indicates  that  their  cause  is  to  be  sought  for  upon  the 
facial  side.     Sometimes,  the  mucous  membrane  of  the  cheeks 

*  Op.  cit.,  p.  49. 


254:  ATROPHIES. 

and  lips  is  raised  into  a  fold  opposite  the  dental  arches.  In 
many  cases,  a  tendinous  expansion  is  observed  upon  the  facial 
surface  of  the  gums  of  the  lower  jaw,  which  gradually  becomes 
narrower  and  terminates  with  a  ridge  of  connective  tissue  which 
is  attached  to  the  neck  of  a  bicuspid  or  molar  tooth.  It  may 
be  well  to  consider  in  future  cases,  whether  any  relation  exists 
betw'een  the  defects  upon  the  neck  of  the  tooth  and  these  folds 
or  ridges.* 

Gums. — The  clinical  appearances  presented  by  senile  atrophy 
of  the  gums  comprise,  chiefly,  loss  of  their  red  color  and  uniform 
turgescence.  The  color  is  changed  to  a  gray-reddish,  gray- 
yellowish  and,  sometimes,  blue-reddish  when  the  venous  charac- 
ter is  in  excess,  in  Avhich  latter  cases  circumscribed  swellings  occur 
here  and  there.  The  dimensions  of  the  gums  are  diminished, 
since  the  margins  recede  from  the  necks  of  the  teeth.  Not  in- 
frequently, superficial  erosions  occur  which  are  covered  with  a 
thin  discolored  layer.  Generally,  the  gingival  margins  of  the 
lower  incisors  are  the  first  to  be  affected  with  senile  atrophy; 
those  of  the  upper  incisors  are  less  frequently  involved  than 
the  preceding,  and  those  of  the  lower  molars  and  bicuspids,  also, 
are  more  often  affected  than  those  of  the  corresponding  upper 
teeth. 

In  senile  atrophy  there  ensues  an  attenuation  of  the  papillary 
portion,  corium,  and  submucous  connective  tissue,  together  with 
a  wasting  of  the  contiguous  periosteum  of  the  alveolar  processes. 
The  epithelial  layers  become  quite  dry  and  hard,  and  exfoliate, 
leaving  the  jaws  covered  with  a  layer  of  cells  undergoing  a  fatty 
degeneration.  The  attachment  of  the  gums  to  the  necks  of  the 
teeth  is  loosened.  The  papillie  of  the  gums  are  flattened,  their 
parenchyma  is  clouded  by  a  molecular  fat-granular  mass,  the 
capillaries  are  obliterated.  The  nerve-trunks  of  the  submu- 
cous connective  tissue  acquire  a  molecular  cloudiness,  and  their 
more  delicate  branches  are  no  longer  recognizable,  in  conse- 
quence of  the  cloudiness  of  the  contents  of  the  nerve-tubes,  and 
of  the  connective-tissue  investments.  The  connective-tissue 
cells  and  their  nuclei  present,  in  places,  a  shrivelled  appearance. 
The  connective  tissue  is  sclerosed. 

*  Comp.  the  remarks,  p.  175. 


GUMS — ROOT-MEMBRANE  —  ALVEOLUS.  255 

Various  causes  may  give  rise  to  a  premature  atrophy,  among 
which  may  be  enumerated  abrasion  of  the  contiguous  dental 
crowns  in  an  oblique  direction,  neglect  of  cleanliness,  accumu- 
lation of  tartar  upon  the  necks  of  the  teeth  and  the  adjacent 
coronal  portions. 

Atony  of  the  Gums. — From  the  fact  that  the  first  indications 
of  that  aifection  of  the  blood  called  scorbutus  are  presented  by 
the  gums,  which  acquire  a  deep  red  color,  become  spongy  and 
bleed  spontaneously,  it  has  been  customary  to  apply  the  term 
scorbutic  to  all  those  affections  of  the  gums  which  present  one 
or  more  of  the  above  appearances,  although  they  may  have  noth- 
ing in  common  with  scorbutus,  except,  perhaps,  a  few  symp- 
toms. The  condition  of  sponginess  and  laxity  of  the  tissue,  and 
even  those  changes,  also,  which  are  induced  by  tartar,  are  de- 
scribed as  an  atonic  condition. 

Lax  gums  present  a  dark-red  color,  a  swollen,  spongy,  and 
inelastic  texture;  the  margins,  which  should  form  a  firm  invest- 
ment around  the  necks  of  the  teeth,  are  swollen  and  uneven, 
recede  from  the  necks,  or,  as  is  the  case  frequently,  cover  over 
half  the  crown.  The  points  of  junction  of  the  gingival  arches 
upon  two  adjacent  teeth  are  transformed  into  shapeless  masses. 
Under  even  very  slight  contact,  an  effusion  of  dark-red  blood 
ensues.  In  some  cases,  this  condition  involves  the  entire  gums, 
in  others,  it  is  limited  to  a  portion  of  them.  As  it  is  impossi- 
ble, with  such  a  condition,  to  keep  the  teeth  clean,  tartar  ac- 
cumulates beneath  the  lax  and  swollen  gums  and,  in  tins  case,  is 
the  result  and  not  the  cause  of  the  affection.  Passive  conges- 
tions, induced  by  the  atony  of  the  organic  muscular  fibres  of 
the  bloodvessels,  give  rise  to  hemorrhages  which,  in  rare  cases, 
are  so  severe  as  to  be  checked  with  difficulty. 

Root-Membrajste  and  Alveolus. — In  old  age,  the  root-mem- 
brane becomes  thicker,  more  compact,  less  succulent,  firmer, 
more  cloudy,  and  is  more  adherent  to  the  root  and  to  the  interior 
of  the  socket  by  means  of  fibrous  tissue  Avhich  is  insinuated  be- 
tween it  and  the  above  surfaces;  hence  it  acquires  a  felted  ap- 
pearance and,  sometimes,  the  lustre  of  tendon.  The  histological 
changes  in  it  are  analogous  to  those  presented  by  the  atrophic 
gum. 


256  ATROPHIES. 

Calcifications  are  not  infrequent  occurrences  in  the  root-mem- 
brane of  old  age.  Sometimes,  they  are  found  in  the  form  of 
small  granular  concretions ;  at  others,  they  present  larger  globu- 
lar bodies  which  have  a  strong  refractive  power;  in  some  in- 
stances, they  are  without  any  recognizable  structure,  in  others, 
they  present  a  radiated  or  concentric  lamination;  they  produce 
the  phenomena  of  double  refraction,  and  when  treated  Avith  di- 
lute hydrochloric  acid,  a  decomposition  ensues  with  the  liberation 
of  bubbles  of  gas,  and  a  deposit  of  an  organic  basis-substance. 
(Atlas,  Fig.  121.) 

It  is  a  notable  fact  that  ossification  of  the  root-membrane  has 
never  been  observed,  at  least  in  man,  notwithstanding  the  fre- 
quent occurrence  of  calcifications. 

The  eifects  of  its  atrophy  may  be  traced  partly  in  the  cement 
of  the  tooth  and  partly  in  the  socket.  The  cement,  which,  usuall}', 
has  become  thicker  with  advancing  age,  undergoes  resorption 
{vide  supra),  and  the  socket  likewise  is  similarly  afi'ected.  The 
extent  of  the  resorption  upon  the  socket  bears  a  direct  relation 
to  the  deposit  of  osseous  layers  upon  the  cement,  and  is  most 
apparent  at  the  closed  extremity  of  the  former  from  the  fact 
that  the  cement  layers  are  more  numerously  disposed  near  the 
apex  of  the  root.  The  Avasting  of  the  socket  occurs  upon  the 
free  margin,  is  still  more  apparent  in  the  vicinity  of  the  latter, 
especially  upon  the  facial  side,  and  is  distinguished  by  an  in- 
creased porosity.  The  foramina  in  the  alveolar  wall,  for  the 
transmission  of  bloodvessels  and  nerves,  become  broader,  their 
osseous  margins  are  sharpened  to  a  thin  edge.  Excavations 
produced  by  resorption,  such  as  have  been  referred  to  frequently, 
may  be  found  in  suitable  thin  sections,  and  dense  connective- 
tissue  substances  are  met  with,  associated  with  the  obliteration 
of  the  bloodvessels  and  nerves.  Sometimes,  adjacent  foramina, 
by  the  resorption  of  their  borders,  are  united  so  as  to  form  a 
quite  large  aperture  with  a  festooned  margin. 

As  the  resorption  of  the  osseous  substance  of  the  socket  ad- 
vances round  about  the  alveolar  border,  the  walls  of  the  socket, 
the  facial  especially,  become  shorter,  the  gums  recede  at  the 
same  time,  and  the  neck  and  contiguous  portions  of  the  roots, 
sometimes,  even  as  far  as   the  apices,  are  exposed.     In  conse- 


MAXILLARY    PERIOSTEUM    AND    MAXILLARY    BONES.       257 

quence  of  this  process,  the  attachment  of  the  teeth  becomes 
loosened,  and  all  the  more  so  Avhen  there  is  a  contemporaneous 
resorption  of  the  cement. 

Wasting  of  the  sockets  generally  occurs,  primarily,  upon  those 
teeth  whose  gums  present  evidences  of  atrophy. 

Maxillary  Periosteum  and  Maxillary  Bones. — Atrophy 
of  the  former  presents  the  same  morphological  changes  as  the 
periosteum  of  the  root. 

Senile  wasting  of  the  hone  is  accompanied,  in  many  cases,  by 
a  marked  fatty  metamorphosis  of  the  soft  parts  contained  in  the 
medullary  spaces  and  canals,  whereby  a  yellowish  fat  pervades 
the  osseous  substance,  which  imparts  a  greasy  sensation  to  the 
touch.  As  fatty  degeneration  of  the  medullary  matter  becomes 
extensive,  the  osseous  lamellae,  which  have  become  attenuated, 
are  hidden  from  view  by  the  general  fatty  appearance  imparted 
by  the  former.  The  medullary  spaces  become  expanded  and 
the  cortical  substance  is  reduced,  finally,  to  a  thin  plate.  If  the 
senile  wasting  is  unaccompanied  by  fatty  degeneration,  these 
appearances  are  all  the  more  evident. 

The  upper  jaw,  with  its  thin  cortical  substance,  displays  the 
senile  rarefaction  of  the  bone  much  more  distinctly  than  the 
lower  jaw,  with  its  thicker  cortex  and  more  compact  structure 
generally.  The  palatine  process  of  the  upper  jaw,  the  facial 
wall  of  the  antrum  and,  also,  the  horizontal  portions  of  the 
palate  bones,  become  as  thin  as  the  lamina  papyracea  of  the 
ethmoid  bone.  The  branching  Haversian  canals  upon  the  super- 
ficial portions  of  these  bones  present  the  appearance  of  very 
delicate  vascular  ramifications,  which  appear  luminous  with  re- 
flected light  and  opaque  with  transmitted  light.  If  very  thin 
transparent  sections,  which  may  readily  be  made  with  the  scis- 
sors, are  examined,  localities  will  be  found  which  do  not  contain 
any,  or  only  a  few  bone-corpuscles,  and  present,  principally,  ex- 
cavations produced  by  resorption.  In  such  places,  a  peripheral 
has  succeeded  the  above-mentioned  central  resorption  in  the 
cancelli  of  the  bone.  The  extreme  degree  of  brittleness  of  the 
bone  incident  to  old  age  approaches  the  condition  which  Lob- 

17 


258  ATROPHIES. 

stein*  described  as  osteopsathyrosis  {fragilitis  viti'ea),  and  Rok- 
itanskyt  as  excentrie  atropliy. 

The  marked  brittleness  of  senile  jaws  is  to  be  borne  in  mind 
by  the  practical  dentist,  when  he  is  called  upon  to  extract  teeth 
still  firmly  implanted,  on  account  of  caries,  or  to  adapt  an  arti- 
ficial set,  since,  even  with  all  possible  care  in  the  operation  of 
extraction,  particularly  with  the  posterior  molars  of  the  upper 
jaw,  a  fracture  of  the  contiguous  portion  of  the  jaAV  is  very 
easily  produced,  which  is^  all  the  more  troublesome,  from  the 
fact  that  the  parts  unite  very  slowly. 

The  processes  which  ensue  in  the  alveoli,  whether  the  teeth 
fall  out  spontaneously  or  are  extracted  artificially,  are  essenti- 
ally the  same,  and  their  description  is  introduced  here  because, 
without  a  thorough  knowledge  of  the  process  of  cicatrization, 
the  changes  which  ensue  in  atrophy  of  the  jaws  cannot  be  ap- 
preciated, and,  moreover,  the  process  is  accompanied  by  atrophy 
of  the  socket.  Heider  and  Wedl  published  a  series  of  investi- 
gations with  reference  to  this  subject.^ 

When  a  tooth  is  extracted,  the  bloodvessels  and  nerves  of  the 
periosteum  of  the  root  with  the  connective  tissue  accompanying 
them,  and  the  afferent  and  efferent  vessels  of  the  pulp,  together 
with  the  nerves  in  relation  with  them,  are  torn  away,  and  the 
socket,  deprived  of  the  tooth,  is  filled  with  coagulated  blood 
which  serves  as  a  natural  plug  in  checking  further  hemorrhage. 
If  the  socket  and  gums  receive  no  more  injury  than  is  incident 
to  the  mere  separation  of  the  tooth,  then  the  gums  maintain 
their  normal  color  and,  after  a  few  days,  their  free  margins  are 
found  to  be  approximated  towards  each  other ;  between  them, 
a  pale  grayish  substance,  decolorized  fibrin  of  the  blood,  is 
frequently  observed,  which,  sometimes,  deceives  the  patients,  so 
that  they  not  infrequently  return  to  the  dentist  with  the  idea 
that  they  have  discovered  suppuration  in  the  wound.  In  cases 
where  the  gums  are  not  lacerated  or  bruised  and  the  socket  is 
not  fractured,  the  cicatrization  always  ensues  without  any  sup- 
puration; indeed,  the  whole  process  is  unattended  with  pain,  and 

*  Path.  Anat.  iibers.  von  Neurohr.,  Bd.  ii,  p.  179. 

f  Manual  of  Path.  Anat.,  trans,  by  C.  H.  Moore,  vol.  iii,  p.  113. 

+  Viertelj.  f.  Zahnheilk.,  1865. 


MAXILLARY    PERIOSTEUM    AND    MAXILLARY    BONES.      259 

in  a  few  weeks  the  patients  are  able  to  chew  upon  the  side  from 
which  the  tooth  was  extracted.  But  when  teeth  are  removed 
during  the  existence  of  an  inflammation  of  the  root-membrane, 
painful  sensations  persist  for  several  days  within  the  socket, 
and,  in  very  rare  cases,  an  acute  very  intense  pain,  without  any 
definite  inflammatory  symptoms,  succeeds  the  extraction  of  a 
tooth. 

The  root-membrane,  especially  with  teeth  extracted  from 
jaws  of  young  persons,  remains  attached  in  the  form  of  a 
closely  adherent  investment,  extending  from  the  neck  to  the 
apex  of  the  roots,  and  the  vascular  ramifications,  injected  with 
the  blood,  may  be  distinctly  traced.  In  most  cases,  however, 
the  contiguous  portion  of  the  membrane  is  torn,  so  that  a  part 
of  it  remains  adherent  to  the  alveolus,  while  the  remainder  is 
attached  to  the  extracted  tooth.  That  portion,  on  the  other 
hand,  which  is  in  immediate  relation  with  the  submucous  layer 
of  the  gums  and  is  distinguished  by  its  more  compact  structure 
and  its  numerous  nerves  and  vascular' plexuses,  is  always  sepa- 
rated from  its  attachment  to  the  neck  of  the  tooth.  Since  then, 
in  most  cases,  the  root-membrane  is  partially,  sometimes,  even 
entirely,  separated  by  the  extraction  of  a  tooth,  and  frequently, 
indeed,  is  destroyed  by  a  previous  morbid  process,  without 
eff'ecting  any  variation  in  the  phenomena  of  the  cicatrization,  it 
cannot  be  claimed  that  the  root-membrane  has  any  share  in  the 
latter  process.  The  alveolus  undergoes  entire  resorption,  since 
no  trace  of  it  can  be  discovered  in  the  completed  cicatrix. 

If  an  entire  series  of  macerated  alveolar  cicatrices  are  ex- 
amined in  the  first  stages  of  the  process,  by  means  of  horizontal 
and  longitudinal  sections,  it  will  be  seen  that,  first  of  all,  osse- 
ous trabeculas  with  free,  pointed,  or  clavate  extremities,  are  de- 
veloped into  the  cavity  previously  occupied  by  the  root,  where 
they  unite  with  others.  Similar  trabeculse  penetrate  from  the 
alveolar  border  and  join  with  those  which  extend  from  the  former 
wall  of  the  socket;  these  together  form  a  spongy,  slender, 
framework  of  osseous  substance  which  fills  up  the  cavity,  near 
the  superficial  portion  of  which  a  fossa-like  depression  is  still 
perceptible,  and  this  disappears  more  and  more,  as  the  cicatri- 
zation progresses  (Atlas,  Fig.  132) ;  the  delicate,  porous,  osseous 


2G0  ATROPHIES. 

lavor  of  tlie  socket  and  its  free  margin,  likewise,  gradually  dis- 
appear. ^Vascularized,  connective-tissue  granulations  form  the 
centre  of  ossification  of  the  cicatrix  ;  these  grow  out  from  the 
gaps  of  the  alveolus,  and  become  ossified ;  thev  also  appear  to 
give  rise  to  the  resorption  of  the  latter. 

The  laceration  of  the  gum,  produced  by  its  separation  from 
the  neck  of  the  tooth,  is  healed  contemporaneously  with  the 
granulation  in  the  socket.  At  the  commencement  of  the  cica- 
trization of  the  membrane,  very  soft,  deep-red  papillae  of  con- 
nective tissue,  which  bleed  easily  (granulations — Fleischwarz- 
chen),  are  observed  growing  out  from  the  margins  of  the  wound, 
and  these  soon  cover  the  socket.  The  papillae  become  flattened, 
coalesce,  and  then  there  is  presented  a  swollen,  succulent,  vas- 
cularized cicatrix  of  the  mucous  membrane,  which  is  smooth 
upon  its  outer  surface  and  covered  with  epithelial  scales. 

The  second  stage,  that  of  consolidation,  now  succeeds  to  the 
first.  The  swelling,  redness,  and  succulency  diminish,  the 
pallid,  cicatricial  tissue  becomes  more  compact  ;  it  presents  for 
a  considerable  period,  a  shallow  groove,  with  slightly  swollen 
margins  in  close  proximity  to  each  other,  which  follows  the  di- 
rection of  the  alveolar  border  and,  eventually,  acquires  nearly 
the  consistence  of  tendon.  Perpendicular  sections  of  such  a 
dense  cicatrix  of  the  gum  display  a  gradual  disappearance  of 
the  papillary  portion,  in  the  vicinity  of  the  cicatrix  (Atlas,  Fig. 
117),  leaving  only  a  flattened  corium  which  presents  a  few, 
slight  elevations  and  depressions  and  is  covered  with  a  thick 
layer  of  laminated  epithelium.  The  bloodvessels  and  nerves, 
which,  in  the  gum,  were  uniformly  disposed,  since  branches  ex- 
tended perpendicularly  towards  the  papillae  from  the  horizon- 
tally disposed  vessels  and  nerves,  assume  in  the  cicatricial  tissue 
a  more  oblique  arrangement  and  irregular  distribution.  The 
bloodvessels  are  obliterated  as  the  condensation  and  thickening 
of  the  cicatrix  increases,  and  the  latter  undergoes  a  correspond- 
ing contraction.  Finally,  a  tense,  sharp  ridge  is  formed,  not 
infrequentl}^,  along  the  cicatrized  alveoli. 

Coincident  with  the  consolidation  of  the  cicatrix  of  the 
mucous  membrane  occurs  that  of  the  bony  callus.  That  portion 
of  the  maxillary  periosteum  which  invests  the  outer  surface  of 


MAXILLARY    PERIOSTEUM    AND    MAXILLARY    BONES.       261 

the  cicatrix,  becomes  very  dense,  and  consists  of  tendon-like, 
tough  bundles  of  fibres  which  are  intimately  united  with  the 
superficial  bony  substance.  The  osseous  lamelloe  \Yithin  the 
socket  are  more  closely  compacted,  especially  near  the  masti- 
cating surface,  this  condition  being  more  distinctly  marked  in 
the  under  than  in  the  upper  jaw. 

When  only  one  tooth  is  removed,  the  teeth  adjacent  to  the 
socket  become  approximated  so  closely,  that  the  cicatrix  disap- 
pears, apparently,  more  properly  speaking,  becomes  partially 
concealed.  Hunter  called  special  attention  to  this  process  and 
illustrated,  in  a  very  instructive  manner,  the  changes  of  posi- 
tion. On  examination,  namely,  it  will  be  found  that  a  crescent- 
shaped  depression  remains  upon  the  cicatrized  alveolar  border, 
extending,  upon  either  side,  to  the  borders  of  the  adjacent  teeth 
which  are  still  retained.  In  the  upper  jaw,  this  depression  is 
directed  downAvards,  and  upwards  in  the  lower  jaw,  its  greatest 
depth,  corresponding  with  the  longitudinal  axis  of  the  pre-ex- 
isting alveolus,  measures  about  one-fourth  that  of  the  axis 
mentioned. 

When  the  cicatrization  involves  two  or  more  contiguous 
sockets,  the  perpendicular  septa  between  them  undergo  a  partial 
resorption,  and  from  both  the  facial  and  lingual  walls  a  bevelled, 
sharp-edged  callus  is  developed,  composed  of  a  compact  cortical 
substance  (Fig.  80).  Sometimes  the  cicatrix  is  more  flattened 
and  the  projecting  lamella3  upon  its  surface  lock  into  one  another, 
presenting,  not  infrequently,  an  appearance  similar  to  that  of  a 
bony  suture.  Small,  irregular,  pitted  depressions  filled  with 
sclerotic  connective  tissue  are  often  met  with  upon  the  site  of 
the  cicatrix,  or  a  shallow' groove  inclosed  by  Avails  with  notched, 
tuberculated  edges.  (Atlas,  Fig.  131.) 

The  process  of  cicatrization  experiences  interruptions  in  con- 
sequence of  diseases  of  the  gum,  socket  or  maxillary  periosteum. 
Abscesses,  especially,  which  have  their  origin  in  the  root-mem- 
brane of  a  tooth,  may  be  adduced  with  reference  to  this  point ; 
these  frequently  spread  over  the  alveolar  process,  give  rise  to  a 
destruction  of  the  bony  substance  and  involve  the  gums  and 
periosteum.  Under  such  circumstances,  the  callus,  particularly 
in  the  vicinity  of  the  upper  molar   and  wisdom  teeth,  becomes 


262 


ATROPHIES. 


distorted,  spreads  over  a  greater  surface  and  is  studded  Avith 
irregular,  flattened  tubercles  and  corresponding  depressions. 
The  process  of  ossification  may  even  be  arrested  here  and  there, 
as  is  manifested  by  the  abundant  deposits  of  calcareous  salts 
without  evidences  of  further  organization.     Sometimes  the  ex- 


tremity of  one  or  another  of  the  roots  remains  inclosed.  The 
submucous  connective  tissue  of  the  gum  degenerates  into  a 
callous,  cartilaginous,  tuberculated  tissue,  and  is  intimately 
united  with  the  felted,  tendinous  portions  of  the  maxillary 
periosteum. 

Further,  the  process  of  cicatrization  may  be  interrupted  by 
recurrent  abscesses  of  the  gum,  or  arrested  by  a  protracted  sup- 
puration in  the  bone;  the  pus,  in  some  instances,  does  not  make 
its  escape,  but  the  cavity  of  the  abscess,  shut  in  by  the  callous 
connective  tissue,  becomes  obliterated,  and  the  pus  is  found 
transformed  into  an  unctuous,  caseous  mass.  The  region  of  the 
tuberosity  of  the  upper  jaw,  mentioned  above,  is,  likewise,  the 
more  frequent  seat  of  such  an  arrest.  (Atlas,  Fig.  139.) 


*  Fig.  80  shows  a  median  section  through  the  posterior  segment  of  a  lower 
jaw,  together  with  the  cicatrized  sockets  of  the  molar  teeth.  The  inferior 
dental  foramen  is  seen  at  (n) ;  the  inferior  dental  canal  is  bisected  in  its 
length;  above  and  below  the  latter  extends  the  spongy  osseous  substance. 
The  cicatrization  is  entirely  completed  ;  the  alveoli  have  disappeared  and, 
towards  the  outer  surface,  a  compact  bony  substance  (b),  corresponding 
with  the  firm  sharp-edged  callus,  has  been  formed.     Natural  size. 


MAXILLARY    PERIOSTEUM    AND    MAXILLARY    BONES.      263 

A  fracture  of  the  alveolus,  if  limited  to  the  site  of  the  ex- 
tracted tooth,  does  not  interfere  with  the  healing  process  unless, 
perhaps,  an  irritation  of  the  contiguous  gum  is  produced  bj  the 
sharp  edges  or  points,  or  loose  spicula  remain  within  the  socket, 
which  cause  pain  and  give  rise  to  suppuration  that  continues 
until  the  necrosed  spicula  are  expelled,  or  removed  by  operative 
interference.  At  the  part  corresponding  with  the  fracture,  the 
cicatrix  presents  a  more  contracted  appearance,  and  its  surface 
is  upon  a  deeper  level.  When,  however,  the  fracture  extends 
across  the  alveolus  of  an  adjacent  tooth  with  a  permanent  loss 
of  the  fragment,  the  socket  is  not  reproduced  and,  as  a  result 
of  this,  the  gum  recedes  and,  consequently,  the  tooth  becomes 
loose. 

With  adults  and  those  whose  teeth  are  still  firmly  implanted, 
cicatrization  occupies  a  period  of  three  to  six  months,  generally, 
but  it  is  by  no  means  at  an  end  when  the  cicatrix  of  the  gum  is 
completed,  since  the  formation  of  the  bony  callus  together  with  the 
resorption  of  the  osseous  substance  in  the  neighborhood  require 
months  longer  than  the  above  mentioned  period.  The  reverse 
is  the  case  with  teeth  which  have  been  quite  loose,  from  the  fact 
that,  in  proportion  to  their  looseness,  the  bottom  of  their  sockets 
have  already  become  more  or  less  filled  with  new  osseous  sub- 
stance and  the  alveolar  margins  have  already  undergone  resorp- 
tion, so  that  cicatrization  in  these  cases  may  be  completed  in  a 
comparatively  short  period,  sometimes  in  four  to  six  weeks. 
Practitioners  are  well  aware  that  the  cicatrices  are  subject  to 
variations  in  form  for  a  long  time  subsequent  to  the  extraction 
of  teeth,  since  it  is  a  frequent  occurrence,  that  plates  which 
have  been  adapted  six  months  after  the  extraction  of  the  teeth, 
become  displaced  in  a  few  months  and  no  longer  occupy  the  site 
from  which  the  teeth  were  removed  originally.  Casts  of  the 
jaw,  taken  at  this  latter  period  and  compared  with  those  of  the 
earlier  periods,  also  indicate,  conclusively,  the  occurrence  of 
changes  of  form. 

The  subsequent  variations  in  the  position  of  the  adjacent  teeth 
during  the  process  of  cicatrization  form  a  subject  of  consider- 
able importance.  In  order  to  obtain  a  thorough  insight  into 
this  process,  it  is  of  advantage  to  remove  either  the  facial  or 


264 


ATROPHIES. 


lingual  wall  from  a  scries  of  macerated  jaws  in  which  the  teeth 
are  defective,  in  order  that  we  may  be  able  to  obtain  an  accurate 
idea  of  the  location  of  tlie  respective  roots. 

The  deviation  from  the  normal  position  may  be  expressed  in 
general  terms  as  consisting  in  an  inclination  towards  the  cicatrix 
of  the  crowns  of  the  teeth  adjacent  to  the  latter,  which  deviation 
is  most  distinctly  marked  Avith  the  largest  teeth,  as  the  molars. 
It  is  exceedingly  instructive  to  observe  the  diiference  in  the  de- 
viation presented  in  those  cases  where  the  teeth  are  defective 
upon  one  side  only.  If  the  coronal  portion  of  one  of  the  above- 
named  teeth  is  tilted  forwards  in  consequence  of  the  absence  of 
the  adjacent  tooth  in  front,  the  anterior  segment  of  the  crown 
becomes  depressed  below,  and  the  posterior  is  raised  above  its 
previous  level,  to  a  degree  varying  with  the  amount  of  the  in- 
clination. The  root  portion  necessarily  experiences  a  corres- 
ponding backward  displacement  and  is  elevated  slightly  (Fig. 
81).  In  addition  to  the  above  approximation  of  the  axis  of  the 
tooth  towards  the  horizontal   line,  an  inclination  of   a  few  de- 


FlCx.  81.* 


grees  towards  the  median  line  of  the  jaw,  also,  occurs,  sometimes, 
indeed,  the  lingual  wall  of  the  crown  of  a  wisdom  or  molar  tooth 
experiences  a  slight  rotation  towards  the  median  line  and  pos- 


*  Fig.  81. — Eight  half  of  a  lower  jaw  from  which  the  facial  wall  has  been 
removed  in  order  to  show  the  approximation  of  the  second  bicuspid  and 
second  molar  teeth  towards  each  other  within  the  sockets,  subsequent  to  the 
loss  of  the  first  molar.  The  crowns  are  almost  in  contact  near  tlie  mastica- 
ting surfaces,  while  their  roots  diverge  from  each  other.  Two-thirds 
natural  size. 


MAXILLARY    PERIOSTEUM    AND    MAXILLARY    BONES.       265 

teriorly.  If  the  alveolar  cicatrix  occupies  the  place  of  three 
or  four  teeth,  e.  g.,  the  tAvo  bicuspids  and  first  molar  or  all  the 
molars,  that  portion  of  the  alveolar  process  Avhich  remains  op- 
posite the  angle  of  the  lower  jaw,  together  with  whatever  teeth 
are  still  retained,  sink  down,  so  that  they  occupy  a  lower  level 
than  the  corresponding  teeth  upon  the  other  side  where  such  a 
defect  does  not  exist.   . 

Inclinations  of  the  wisdom  and  molar  teeth  of  the  upper  jaw,  in 
connection  with  the  loss  of  teeth,  are  less  marked,  as  a  rule,  and 
in  certain  respects,  present  relations  the  reverse  of  those  pre- 
sented by  the  same  teeth  of  the  lower  jaw;  the  anterior  segment 
of  the  crown  becomes  raised,  somewhat,  the  posterior,  depressed 
to  an  equal  degree,  producing  a  greater  or  less  dislocation  of 
the  posterior  portion  of  tlie  neck  of  the  tooth  from  out  the 
socket.  Axial  rotations  are  less  liable  to  occur,  from  the  fact 
that  the  corresponding  teeth  of  the  upper  jaw  are  supplied  with 
three  divergent  roots.  The  forward  inclination  of  the  second 
upper  molar,  subsequent  to  the  loss  of  the  first,  may  retard  the 
eruption  of  the  wisdom  tooth  in  certain  cases  (comp.  p.  129). 

Dislocations  of  the  bicuspids  are  not  so  notable,  in  most  cases, 
since  they  are  held  in  their  positions  by  the  canine  teeth  which, 
as  is  well  known,  are  the  last  to  fall  out  in  old  age  and  are  least 
liable  to  be  affected  with  caries.  When  cicatrization  of  the 
socket  of  the  first  bicuspid  takes  place,  the  second  bicuspid 
presses  towards  the  canine  tooth  and  experiences  a  slight  axial 
rotation  anteriorly  and  an  inclination  towards  the  median  line 
of  the  jaw. 

Subsequent  to  the  completion  of  the  cicatrization  of  the  socket 
of  the  lateral  incisor,  the  central  becomes  inclined  towards  the 
canine,  now  and  then  with  a  slight  rotation  of  its  anterior  coronal 
surface  towards  the  latter  tooth.  If  the  incisors  on  both  the 
right  and  left  sides  are  removed,  then  the  crowns  of  the  retained 
canines  become  inclined  towards  each  other.  If  a  canine  tooth 
is  wanting,  the  lateral  incisor  is  inclined  in  the  direction  of  the 
cicatrix  to  a  decree  commensurate  with  the  smaller  bulk  of  its 
root  in  comparison  with  that  of  the  canine. 

The  changes  of  position,  produced  by  alveolar  cicatrices, 
necessarily  have  an  influence  upon  the  act  of  mastication  which 


26G  ATROPHIES. 

becomes  variously  modified ;  the  age  of  an  individual,  also,  is  an 
element  of  importance  in  this  connection,  for,  with  young  per- 
sons whose  jaws  are  not  completely  developed,  the  bony  cicatrix 
frequently  is  so  slight  that  scared}^  any  deviation  of  the  con- 
tiguous teeth  ensues,  and  their  crowns  frequently  come  into 
relation  with  each  other  in  a  normal  position. 

Finally,  the  question  arises,  what  influence  does  the  extraction 
of  the  milk  teeth  exercise  upon  the  development  of  the  perma- 
nent teeth  ?  The  eifect  of  cicatrization  in  these  cases  varies 
according  to  the  age  of  the  child  and  the  kind  of  tooth.  The 
older  the  child,  the  nearer  is  the  period  for  the  eruption  of  the 
corresponding  permanent  tooth,  and  so  the  latter  process  will 
be  expedited  by  the  extraction ;  on  the  other  hand,  when  the 
milk  teeth  are  extracted  too  early,  a  callus  is  formed  which 
retards  the  eruption  of  the  permanent  teeth  and  may  deflect 
them  from  their  normal  course.  The  eruption  of  the  permanent 
bicuspids  is  retarded,  merely,  by  the  thickening  of  the  superficial 
portion  of  the  capsule  occasioned  by  the  callus,  but  the  incisors 
and  canines,  according  to  their  location  with  reference  to  the 
pre-existing  milk  teeth,  may  also  be  deflected  from  their  normal 
course  by  the  thickened  alveolar  wall  in  front  or  behind  them. 

When,  in  old  age,  a  marked  wasting  of  the  alveolar  process 
and  sockets  ensues,  associated,  frequently,  with  a  chronic  in- 
flammation of  the  periosteal  membranes  of  the  roots,  the  teeth 
which  still  remain  gradually  become  deprived  of  their  support, 
since  the  greater  portion  of  the  roots  become  denuded  and 
merely  their  extremities  remain  fixed  in  the  jaw.  The  teeth, 
consequently,  acquire  abnormal  positions  and  become  displaced 
towards  the  face  or  tongue,  under  the  influence  of  mastication 
(Fig.  82).    • 

With  edentulous  jaws  of  advanced  age,  the  reverse  relations 
obtain  with  reference  to  the  prominence  of  the  jaws.  When  all 
the  teeth  are  present  and  properly  located,  the  upper  set  pro- 
jects somewhat  beyond  the  lower ;  but  the  toothless  upper  jaw 
of  old  age  recedes  to  such  an  extent  that  the  toothless  lower 
jaw  projects  considerably  in  advance  of  it  (Fig.  83).  This  ap- 
pearance is  to  be  explained  in  the  following  manner.  The 
alveoli  are  deeper  and  occupy  a  greater  extent  of  space  in  the 


MAXILLARY    PERIOSTEUM    AND    MAXILLARY    BONES.      267 

abundant  spongy  tissue  of  the  upper  jaw,  and  therefore  their 
cicatrices  contract  more  and  acquire  deeper  depressions,  especi- 

FlG.  82.* 


ally  those  corresponding  to  the  large  cavities  occupied  by  the 
molars  with  three  roots,  than  is  the  case  Avith  the  lower  jaw. 


Fig.  83.t 


*  Fig.  82  shows  marked  displacement  of  the  teeth  of  the  upper  jaw,  the 
results  of  senile  wasting  of  the  alveolar  process.  Lateral  view.  The  roots 
of  the  six  remaining  teeth  are  almost  entirely  denuded,  being  attached,  within 
the  remains  of  the  alveoli,  at  their  extremities  onh'.  The  right  central  in- 
cisor (a),  which  is  worn  away  upon  its  incisive  edge,  has  a  nearly  horizontal 
position.  The  crowns  of  the  left  central  incisor  (6),  the  axis  of  which  is 
elevated  at  an  angle  of  about  45°,  of  the  lateral  incisor  (c),  and  the  canine 
(d),  diverge  from  one  another.  The  left  wisdom  tooth  (e),  and  first  right 
molar  (/),  present  the  least  deviation  from  the  normal  position.  The  facial 
wall  of  the  antrum  [g)  has  become  reduced  to  a  transparent  bony  plate,  as 
thin  as  tissue-paper ;  the  posterior  segments  of  the  palatal  plates,  also,  are 
remarkably  thin  and  transparent.  The  rest  of  the  hard,  bony  portions  pre- 
sent a  yellowish  color,  induced  by  fatty  degeneration.  Two-thirds  natural 
size. 

f  Tig.  83  shows  a  view  in  profile  of  a  toothless  upper  and  lower  jaw,  from 
an  aged  person,  in  their  natural  position  with  respect  to  each  other.     The 


268  ATROPHIES. 

■\vhicli  is  more  compactly  formed,  for  the  attacliment  of  its 
powerful  muscles.  The  lower  half  of  the  face  obviously  dimin- 
ishes in  length  to  a  degree  commensurate  with  the  height  to 
which  the  crowns  projected  from  their  sockets,  added  to  the 
entire  depth  of  the  alveolar  processes  in  the  two  jaws.  The 
latter,  seen  in  profile,  form  a  re-entering  angle  in  front,  which 
occasions  a  retraction  of  the  lips  and  the  characteristic  mouth 
of  old  age. 

The  ridge,  formed  along  the  alveolar  cicatrices  after  the  de- 
tachment or  extraction  of  the  teeth,  gradually  loses  its  sharp- 
ness, becomes  rounded  and,  finally,  flat,  with  increasing  age, 
especially  upon  the  posterior  segments  of  the  lower  jaw,  where 
the  cicatrices  acquire  the  form  of  a  continuous,  finely-dentated, 
bony  suture.  The  palatal  processes  of  the  upper  jaw^  become 
flattened  and  form  a  horizontal  bony  roof  to  the  mouth,  between 
which  and  the  facial  wall  the  alveolar  cicatrices  are  elevated  in 
the  form  of  a  blunt  ridge.  Transverse  sections  establish  the 
■fact  that  flattened  cicatrices  undergo  a  progressive  resorption. 
Their  flattened  portions  towards  the  masticating  surface  are 
composed  of  compact  osseous  substance,  several  millimetres  in 
thickness,  the  outer  surface  of  which  presents  an  irregularly 
notched  appearance,  occasioned  by  indentations  produced  by 
resorption. 

The  cicatrices  of  the  gums  of  senile,  toothless  jaws,  are  char- 

resorption  of  the  alveolar  processes  is  complete,  the  process  having  progressed 
to  a  greater  extent  in  the  upper  than  in  the  lower  jaw;  the  former,  also,  is 
retracted  to  a  considerable  distance  towards  the  latter.  The  cicatrized 
alveolar  edge  of  the  upper  jaw  forms  a  curve,  with  its  concavity  directed 
downwards,  while  that  of  the  lower  jaw  has  its  concavity  directed  upwards. 
The  suture  of  the  flattened  palatal  plates  of  the  upper  jaw  projects  in  the 
form  of  a  ridge,  wasting  of  the  bone  having  ensued  everj'where,  in  conse- 
quence of  which  the  fatty  Haversian  canals  are  apparent  upon  the  facial 
wall  of  the  jaw.  The  facial  wall  of  the  inferior  maxillary  arch,  in  conse- 
quence of  the  wasting  of  the  bone,  has  undergone  a  displacement  posteriori}', 
and  the  widened  mental  foramen  has  acquired  a  nearly  horizontal  position. 
The  coronoid  process  is  very  thin,  the  neck  of  the  articular  condyle  is  quite 
narrow,  and  the  articular  tubercle  of  the  temporal  bone  is  flattened.  The 
facial  length  is  diminished  nearly  three  and  a  half  centimetres,  in  conse- 
quence of  the  loss  of  all  the  teeth  and  the  wasting  of  the  alveolar  processes. 
Two-thirds  natural  size. 


MAXILLARY    PERIOSTEUM    AND    MAXILLARY    BONES.       269 

acterized  by  a  very  dry,  callous  condition:  frequently,  also,  they 
present  ridges  of  a  cartilaginous  consistence,  composed  of  de- 
generated connective  tissue,  and  often  contain  one  or  more 
roots  which  may  be  the  source  of  irritation  and  subsequent  ab- 
scesses. Bundles  of  tense  fibrous  tissue  extend  from  the  peri- 
osteal layer  of  the  gums  between  the  serrated  bony  margins  of 
the  cicatricial  substance,  and  are  intimately  united  to  them. 
Whenever  an  irregular  groove  remains  in  consequence  of  a  want 
of  junction  between  the  bony  substance  on  either  side,  it  is  also 
found  to  be  filled  with  firm  fibrous  tissue. 

In  old  age,  the  angle  of  the  lower  jnAV  becomes  more  obtuse, 
resembling,  therefore,  that  of  the  infantile  jaw.  This  change, 
as  Hunter  has  shown,  is  occasioned  by  resorption  of  the  bone  at 
the  angle,  as  is  indicated  to  the  touch  by  the  rough  surface,  and 
this  process  takes  place  in  a  manner  essentially  similar  to  that 
already  described  in  connection  with  senile  cement.  The  in- 
dentations produced  by  resorption  upon  the  surface  of  the  latter 
are,  generally,  small,  and,  on  cross-section,  present  irregular, 
festooned  borders ;  on  close  inspection,  however,  deeper,  dome- 
shaped  concavities  may  also  be  found,  and  even  proliferated, 
young,  osseous  substance,  as  is  the  case  upon  the  cement  of  the 
milk  teeth  at  the  period  of  dedentition  or  upon  senile  teeth. 
Bone-corpuscles,  inclosed  within  a  capsular  investment,  also, 
occur ;  hence,  development  and  resorption  of  osseous  tissue  are 
presented  side  by  side.  This  peripheral  is  succeeded  by  a  jje^'i- 
cellular  resorption  upon  the  interior  of  the  cancelli  or  medullary 
spaces  of  the  bone  which,  in  cross-section,  instead  of  the  finely- 
indented  margins  produced  by  the  openings  of  the  bone  canali- 
culi,  present  the  segments  of  indentations  of  resorption  in  which 
the  usure  of  the  bone-corpuscles  is  apparent.  The  periosteum 
and  endosteum  [medullary  membrane]  are  transformed  into  a 
tense,  firm,  fibrous  mass. 

The  masseter  and  internal  pterygoid  muscles  which  are  at- 
taclwd  to  the  angles  of  the  lower  jaw  participate  in  the  senile 
wasting  of  the  tissues,  as  is  indicated  by  a  diminution  in  the 
quantity  of  the  muscular  substance,  its  pale  color  and  great  fri- 
ability, by  the  fatty  metamorphosis  of  the  muscular  fibrillte  and, 
sometimes,  by  an  abundant  multiplication  of  fat-cells  between 


270  ATROPHIES. 

the  primitive  muscular  fasciculi.  The  movements  of  mastication 
are  performed  with  diminished  energy. 

The  wasting  of  the  coronoid  process  and  condyle  of  the  lower 
jaw  is  quite  marked;  the  circumference  of  the  articular  head  of 
the  condyle  is  diminished,  and  its  surface  presents  numerous, 
small  bony  excrescences,  as  the  cartilaginous  investment  is  de- 
stroyed. 

The  flattening  of  the  articular  eminence  of  the  temporal  bone 
exercises  an  influence  upon  the  act  of  mastication  to  which 
Thomas  Bell*  alludes  as  follows:  "In  children  the  area  of  the 
articular  cavity  for  the  lower  jaw  is  scarcely  greater  than  that 
of  the  condyle  ;  the  articular  eminence  is  not  yet  formed.  The 
movements  consist  simply  in  raising  and  depressing  without  the 
least  approach  to  the  rotation  of  the  jaw.  In  fact,  the  condyle 
is  the  centre  of  movement.  With  old  people,  too,  who  have  lost 
all  their  teeth,  the  lower  jaw  is  simply  moved  up  and  down.  As 
the  teeth  are  absent,  it  i§  only  necessary  to  open  the  mouth 
slightly  for  the  reception  of  food." 

*  Op.  cit.,  p.  51. 


CEMENT.  271 


IV.  HYPERTROPHIES. 

The  augmented  nutrition  of  any  organ  requires  an  increased 
supply  of  nutritive  material  from  the  bloodvessels  which  either 
enter  the  organ  directly  or,  without  entering  it,  effect  the  in- 
terchange of  materials  by  their  close  proximity  to  it.  An 
increased  supply  is  rendered  possible  by  increased  contractility 
of  the  bloodvessels,  and  subsequent  thickening  and  dilatation 
of  their  cavities.  A  continued  irritation  of  the  nerves  involved 
accompanies  this  process.  In  hypertrophy,  the  elementary 
organs  assume  an  unwonted  activity ;  they  increase  in  volume 
and  proliferate  more  largely  than  usual.  While  they  manifest 
augmented  productivity,  their  development  is  frequently  arrested 
at  an  embryonic  stage. 

If,  now,  a  greater  amount  of  formative  material  is  excreted 
from  the  blood  than  can  be  appropriated,  the  accumulated  mate- 
rial must  necessarily  undergo  a  retrograde  metamorphosis,  or 
the  reverse  may  occur,  the  multitude  of  elements  which  are  pro- 
duced may  be  insufficiently  nourished  by  the  formative  material 
Avith  which  they  are  supplied,  and,  therefore,  a  portion  of  them 
are  destroyed. 

In  true  hypertrophy,  the  elementary  organs  are  identical  in 
quality  with  those  originally  belonging  to  the  part ;  their  de- 
viation from  the  normal  condition  has  reference,  for  the  most 
part,  merely  to  the  stage  to  which  their  development  attains, 
and  to  their  disposition,  because  the  ordinary  relations  of  con- 
structive and  destructive  metamorphosis  are  altered.  We  have 
to  consider  hypertrophy  of  the  cement,  periosteum  of  the  root, 
and  gum,  true  hypertrophies  of  tissues  belonging  to  the  cate- 
gory of  connective  substances. 

Cement. — Hypertrophy  of  this  tissue  occurs  along  with  hy- 
pertrophy of  the  periosteum  of  the  root,  since  it  is  induced  by 
a  chronic  irritation  of  the  latter  membrane.  Various  modifica- 
tions are  distinguished  which  present  transitions  from  one  into 


272  HYPERTROPHIES. 

another,  several  of  which  sometimes  occur  together  ;  tliey  are 
based  upon  the  disposition  and  form  of  the  bone-corpuscles,  the 
basis-substance,  the  occasional  vascular  canals,  the  interstitial 
development  of  new  osseous  tissue,  and  the  retrograde  meta- 
morphosis. 

With  reference  to  the  external  form,  a  cap-shaped  variety  is 
distinguished,  in  which  the  hypertrophic  cement  extends  over 
the  greater  portion  of  the  root,  or  invests  it  completely  as  far 
as  the  neck  of  the  tooth,  becoming  gradually  attenuated  towards 
the  non-hypertrophied  portion.  Nodulated,  tuberculated,  warty 
forms  are  designated,  commonly,  as  exostoses,  and  will  be  con- 
sidered in  connection  with  the  subject  of  new-formations. 

When  viewed  with  the  lens,  the  outer  surface  of  hypertrophic 
cement  is  seen  to  be  marked  with  shallow  pits  and  grooves,  to 
which  are  attached,  generally,  the  remnants  of  the  periosteum 
of  the  root.  Its  color  is  rather  light,  frequently  inclining  to 
white,  and  is  quite  conspicuous,  particularly  on  the  yelloAvish 
teeth  of  elderly  persons.  The  apertures  at  the  apices  of  the 
roots,  which  serve  for  the  transmission  of  the  dental  nerves  and 
bloodvessels,  are  often  diminished  in  size,  or  are  occupied  by  a 
growth  from  one  side.  Sometimes,  several,  very  small  apertures 
are  found,  and  in  such  cases,  it  is  easy  to  understand  that  the 
dental  nerves  are  bent  from  their  course,  lacerated,  or  pressed 
upon  by  the  bony  substance  which  is  developed  around  the  ex- 
tremity of  the  canal ;  the  branches,  likewise,  which  are  dis- 
tributed to  the  periosteum  of  the  root  from  the  dental  nerves, 
previous  to  the  entrance  of  the  latter  into  the  dental  canal,  are 
displaced  by  the  abnormal  local  relations,  and  the  occasionally 
severe  neuralgias  consequent  upon  these  conditions  may  be  ex- 
plained by  the  unusual  tension  to  Avhich  the  nerves  are  sub- 
jected. 

As  a  general  rule,  it  may  be  said  that  the  occurrence  is  quite 
rare  upon  the  front  teeth ;  occasionally,  however,  these,  especi- 
ally the  upper  ones,  present  a  notable  hypertrophy.  The  cap- 
shaped  variety  is  observed  more  frequently  upon  the  upper  bi- 
cuspids (Atlas,  Fig.  100),  and  next  in  frequency  it  occurs  upon 
the  wisdom  teeth  with  blended  roots  (Atlas,  Fig.  101).  Fre- 
quently, also,  it  is  found  upon  the  anterior  facial  roots  of  the 


CEMENT.  273 

upper  molars.  Sometimes,  both  facial  roots  are  united  by  ce- 
ment, and,  in  quite  rare  cases,  the  apices  of  the  three  roots  are 
united  by  a  hypertrophic  growth  (Atlas,  Fig.  102).  Now  and 
then,  the  hypertrophy  is  confined  to  the  contiguous  surfaces  of 
these  roots  (Atlas,  Fig.  103).  Upon  the  extremities  of  the 
roots  of  the  lower  molars,  it  forms  a  rounded  knob. 

Upon  close  examination,  it  Avill  be  seen  that  in  some  places 
tolerably  uniform  intervals  are  preserved  between  the  bone-cor- 
puscles, the  long  diameters  of  Avhich  are  disposed  horizontally, 
i.  e.,  are  perpendicular  to  the  axis  of  the  tooth  or  have  a  direc- 
tion parallel  or  at  an  oblique  angle  with  the  latter,  and  in  other 
places  they  are  crowded  together  or  are  situated  far  apart. 
The  former  relations  are  observed  more  particularly  in  concen- 
tric hypertrophies  (Atlas,  Fig.  106),  in  which  numerous  layers 
of  cement  encircle  the  dentine  in  a  manner  similar  to  the  annual 
rings  in  wood.  Generally,  however,  this  lamination  is  limited 
to  certain  localities,  while  in  others  an  excessive  proliferation 
occasions  clusters  of  numerous  bone-corpuscles  and,  occasion- 
ally, cross-sections,  especially,  present  elongated,  isolated  layers 
of  densely  packed  bone-corpuscles,  the  canaliculi  of  which  must 
have  suffered  an  arrest  of  development.  Frequently,  the  bone- 
corpuscles  attain  quite  large  dimensions,  are  abundantly  sup- 
plied with  canaliculi,  which  are  of  considq^able  length  and  fur- 
nished with  anastomotic  loops ;  smaller  bone-corpuscles  are 
sometimes  attached  to  the  sides  of  the  larger  ones,  or  are  blended 
with  them;  large  and  small  ones  also  occur  separately.  When 
they  are  separated  by  very  wide  intervals,  the  intervening 
canaliculi  are  nearly  parallel  with  one  another,  resembling  in 
this  respect,  the  dentinal  canals,  or,  in  some  instances,  are  Avant- 
ing,  and  the  intervals  are  occupied  merely  by  a  finely-granular 
basis-substance. 

Sometimes,  peripheral  resorption  takes  place  in  hypertrophic 
cement  which,  then,  has  a  rough  exterior  and  presents  a  serrated 
appearance  in  cross-sections  (Atlas,  Fig.  116).  The  appear- 
ances produced  by  this  process  are  not  uniform  in  character, 
for,  at  one  part,  the  cement  layers  may  be  affected  but  slightly, 
and  at  others  the  resorption  may  induce  a  total  destruction  of 
them  and  even  involve  the  dentine,  and,  in  many  places,  it  oc- 

18 


274 


HYPERTROPHIES. 


cfisions  a  circumscribed  or  localized  breach  of  substance  (Atlas, 
Figs.  98  and  106).  Again,  especially  upon  the  roots  of  carious 
teeth,  it  attacks  the  peripheral  layers  of  the  cement  at  many 
points  and  involves  the  entire  thickness  of  the  latter  tissue 
and  even  of  the  dentine,  as  far  as  the  cavity  of  the  root,  its 
course  being  marked  by  rough  channels.  It  is  induced  by  a 
proliferation  of  the  connective-tissue  elementary  organs  of  the 
periosteum  of  the  root,  or  suppuration,  and  is  called  perforating 
resorption  (Fig.  84). 


Interstitial  resorption  of  hypertrophic  cement  is  displayed  in 
the  form  of  cavities  of  Avhich  several  types  are  distinguished. 
Some  of  them  present  radiating  canaliculi,  and  hence  they  are 
the  results,  apparently,  of  the  resorption  of  adjacent  bone-cor- 
puscles, while,  in  others,  these  canaliculi  are  absent;  notched 
vacuities,  also,  are  met  with  of  various  dimensions  and  shapes; 


*  Fig.  84  shows  the  rosults  of  resorption  which  extended  from  without  in- 
wards, in  phices  even  as  far  as  the  pulp-canal,  upon  the  roots  of  a  carious 
molar  with  hj'pertrophic  cement.  The  resorption  has  given  rise  to  cup- 
shaped  excavations  (a),  and  occasionally  bifurcating,  flask-shaped  cavities 
[h).  A  very  wide  flask-shaped  cavity,  only  half  of  which  is  represented 
in  the  figure  (c),  extends  through  the  entire  thickness  of  the  cement  and 
dentine,  as  far  as  the  wall  of  the  dental  canal  which,  likewise,  is  eroded 
(usurirt)  to  a  certain  extent.  Minute  examination  shows  the  cavities  to  be 
made  up  of  indentations  which  are  lined  with  a  cloudy  mass.  Magnified 
8(J  diameters. 


CEMENT.  275 

some  present  annular  constrictions,  while  others  occur  in  the 
form  of  flask-shaped  expansions  which  terminate,  frequently,  in 
narrow  necks,  present  lateral  cavities  and  are  filled  with  amor- 
phous calcareous  salts,  fat-granules,  dirty  yellow  pigment,  or  a 
fluid.  As  a  rule,  they  are  met  with  most  frequently  in  the  older 
layers  of  cement  adjoining  the  peripheral  globular  layer  of  the 
dentine,  where  they  form,  sometimes,  irregular,  elongated  cavities 
from  which  processes  extend  far  into  the  dentine.  They  may 
arise  in  various  ways.  Where  several  adjacent  bone-corpuscles 
undergo  resorption,  the  canaliculi  which  radiate  from  the  cavity 
that  is  formed  are  destroyed  as  the  latter  expands.  The  pene- 
tration of  bloodvessels  into  the  cement  frequently  occasions  a 
resorption  of  the  corresponding  portion  of  the  latter,  and  the 
former  may  be  obliterated  and  become  transformed  into  vacui- 
ties or  channels' containing  calcareous  salts  and  the  products  of 
fatty  metamorphosis.  Another  form  of  interstitial  wasting  con- 
sists in  a  granular  disintegration  of  the  intercorpuscular  sub- 
stance which  acquires  a  color  varjnng  between  dirty-yellow  and 
brown.  Portions  thus  aff"ected  pass  imperceptibly  into  the  neigh- 
boring tissue,  and  in  them  the  outlines  of  the  bone-corpuscles  are 
still  recognizable,  except  at  those  parts  where  the  degeneration  is 
very  extensive.  These  instances  of  resorption  which  have  been 
described  are  met  with  most  frequently  upon  carious  roots. 

The  vascular  canals,  which  are  of  frequent  occurrence  in  hyper- 
trophic cement,  penetrate  from  the  outer  surface,  give  off  lateral 
branches  or,  perhaps,  form  a  network  of  ramifications  and  extend 
as  far  as,  and  even  into  the  dentine  and,  generally,  they  form  an 
oblique  angle  with  the  latter  and  are  tolerably  uniform  in  size. 
It  is  a  peculiarity  belonging  to  them  that  their  sheaths  undergo 
an  extensive  calcification  which,  ultimately,  occasions  an  oblit- 
eration of  their  cavities.  Hence,  elongated  channels,  filled  with 
calcareous  granules,  are  met  with  (Atlas,  Fig.  105),  the  hollow 
nature  of  which  is  indicated  by  cross-sections  and,  also,  by  sec- 
tions in  which  the  channels  are  presented  in  their  length,  by 
the  presence  of  air  in  portions  which  have  become  emptied  of 
their  contents.  The  vessels  do  not  completely  fill  the  channels, 
have  thin  walls,  comparatively  wide  cavities,  generally  termi- 


276  HYPERTROPHIES. 

nate  Avith  closed  extremities  and,  only  exceptionally,  contain 
blood. 

The  vascular  canals  sometimes  are  surrounded  by  a  substance 
•\vhicli  forms  an  investment  of  variable  thickness  and  is  sepa- 
rated from  the  basis-substance  by  a  brighter  boundary  layer;  it 
presents  a  notched,  sharply  defined  border,  a  radiated,  granular 
structure,  and  is  to  be  regarded  as  an  external  limiting  layer  of 
rudimentary  osseous  substance  (Atlas,  Fig.  105);  for,  ^vhen 
traced  in  its  further  progress,  groups  of  young  bone-corpuscles 
have  been  found  imbedded  within  it.  Hence,  there  is  presented 
a  development  of  new  osseous  substance  around  the  vascular 
canals,  and  it  may  be  traced  even  as  far  as  the  border  of  the 
dentine. 

Finally,  bone-corpuscles  are  met  with  beneath  the  outer  sur- 
face of  hypertrophic  cement,  in  the  intermediate  portions  or 
even  in  the  vicinity  of  the  dentine,  which,  either  in  pairs  or  in 
groups  of  three  or  more,  are  encapsulated  by  an  indented  highly 
refractive  layer  and  present  an  appearance  as  if  they  were  in- 
serted within  the  proper  layers  of  cement.  The  young  corpus- 
cles, sometimes,  inclose  a  distinct  cellular  body  together  with  a 
nucleus,  and  multiply  by  a  progressive  segmentation ;  generally, 
but  few  canaliculi  radiate  from  them,  and  these  unite  with  the 
adjacent  canaliculi  in  the  same  group,  while  they  do  not  join 
with  those  of  the  concentric  laminge  of  the  cement,  being  cut  off 
by  the  capsular  layer. 

A  twofold  liypertroijliic  groivtli  of  cement  must,  therefore,  be 
distinguished,  namely,  a  peripJiei'al  concentric,  which  conforms 
to  the  disposition  of  the  pre-existing  layers,  and  an  interstitial, 
intercalated  hypertrophy.  The  latter,  probably,  is  brought 
about  by  the  penetration  of  the  branches  of  the  periosteal  blood- 
vessels into  the  cement.  I  have  generally  found  such  a  growth 
upon  cement  in  which  numerous  vascular  canals  have  been  de- 
veloped and,  also,  in  the  hypertrophic  cement  upon  the  teeth  of 
the  hippopotamus,  horse,  cattle,  lama,  and  stag.  It  cannot, 
however,  be  said  that  a  vascular  canal  occurs  in  all  cases- where 
groups  of  young  bone-corpuscles  are  developed ;  it  is  much  more 
reasonable  to  assume  that  the  formative  material  which  induces 
the  resorption  of  the  old  and  out  of  which  the  new  osseous  sub- 


ROOT-MEMBRANE.  277 

Stance  is  developed,  may  permeate  to  a  certain  depth.  The  cir- 
cuL'ition  within  the  canals  of  tlie  hypertrophic  cement  is  quite 
imperfect  and  represents  an  embryonic  stage,  since  canals,  Avith 
closed  -extremities,  are  met  with  very  often,  and  only  excep- 
tionally do  we  find  a  plexus;  indeed,  the  reason  for  the  prema- 
ture calcification  of  the  canals  is  to  be  sought  for  in  this  defec- 
tive  development. 

The  osseous  growth  not  infrequently  extends  beyond  its 
proper  limits  and  encroaches  upon  the  dentine.  Cases  occur  in 
Avhicli  single  bone-corpuscles  or  groups  of  them  have  displaced 
the  dentine,  being  separated  from  the  latter  by  a  hyaline, 
notched,  limiting  layer.  A  similar  occurrence  has  been  referred 
to  before  (Atlas,  Fig.  110),*  in  connection  with  the  resorption 
of  the  roots  of  the  milk  teeth  during  dedentition,  and  we  can 
explain  it  only  as  an  instance  of  interstitial  growth  of  bone. 
The  vascular  proliferations,  which  frequently  penetrate  deeply 
into  the  dentine,  sometimes  are  invested  with  a  layer  of  rudi- 
mentary osseous  substance  containing  bone-corpuscles  which 
are  stunted  in  their  development,  as  may  be  demonstrated  in 
the  interior  of  the  dentine  by  means  of  cross-sections.  Deep 
funnel-shaped  prolongations  of  the  cement-substance  into  the 
dentine  (Atlas,  Fig.  109)  are  met  with  in  a  few  cases.  It  is 
quite  common  to  find  hypertrophy  of  the  cement  in  combination 
with  a  new  growth  of  osseous  substance  upon  the  surface  of  the 
canal  of  the  root,  which  becomes  lined  by  it,  in  some  cases,  for  a 
considerable  distance  from  the  extremity. 

Root-membrane. — In  addition  to  the  senile  form,  an  hyper- 
trophy occurs  as  a  sequel  of  chronic  affections  of  the  root-mem- 
brane, consisting,  essentially,  in  a  thickening  and  a  more  or  less 
advanced  callous  formation.  In  order  to  investigate  this  sub- 
ject, detached  preparations  are  employed  and  also  cross-sections 
which,  perhaps,  it  is  unnecessary  to  add,  should  only  be  made 
upon  decalcified  portions  of  the  jaw  containing  the  corresponding 
roots,  and  all  the  more  from  the  fact  that  there  is  a  question 
respecting  the  connection  of  the  periosteum  of  the  root,  on  one 
side,  with  the  root,  and,  on  the  other,  with  the  alveolus.     The 

*  Comp.  p.  78. 


278  HYPERTROPHIES. 

generally  straight  bundles  of  fibrous  tissue  often  pursue  a  radia- 
ting course  for  the  most  part,  i.  e.,  they  extend  from  the  outer 
surface  of  the  cement,  towards  the  alveolar  wall,  forming  a  series 
of  closely-packed  arches,  and  are  inserted,  by  a  fan-shaped  ex- 
pansion, into  the  osseous  trabeculi^.  During  their  passage,  the 
bundles  inclose  spaces  Avliich,  likewise,  are  traversed  by  thin 
bundles.  These  are  the  depositories  for  the  aggregations  of 
ovoid  cells  which,  here  and  there,  form  radiated  prolongations 
to  the  cavities,  their  number  bearing  an  inverse  proportion  to 
the  density  of  the  thickened  periosteum.  Besides  these  latter 
cells,  and  more  nearly  in  the  course  of  the  bundles,  spindle- 
shaped  cells  occur  which  have  oblong,  frequently  fibre-like, 
elongated  nuclei. 

The  bundles  of  connective  tissue,  especially  in  cases  of  very 
irregular  hypertrophy,  interlace  with  one  another  in  various 
directions,  forming  a  sort  of  felted  work  of  bundles  which 
penetrate  the  enlarged  foramina  in  the  alveolar  wall.  Cross- 
sections  of  periosteum  of  this  description  present,  therefore, 
numerous  protuberances  and  conical  prolongations  (Fig.  85). 
In  consequence  of  the  increase  of  the  fibrillated  tissue  of  the 
periosteum,  its  consistence  becomes  augmented  and  it  may  even 
acquire  a  tendinous  character,  so  that  its  tenacity  and  conse- 
quent power  of  resistance  in  extraction  are  increased. 

The  fringes  presented  by  the  membrane  when  extracted 
along  with  the  root  are,  manifestly,  pulled  out  from  the  vascular 
foramina  of  the  socket  and  consist  of  cloudy  tough  bundles  of 
connective  tissue,  containing  numerous,  usually  shrivelled  nuclei 
and  inclosing  bloodvessels  with  their  external  coats  very  much 
thickened.  They  form  an  intimate,  quite  firm  union  between 
the  root-membrane  and  the  socket,  in  consequence  of  which 
fragments  of  the  alveolar  wall,  particularly  those  portions 
which  correspond  with  the  neck  of  the  tooth,  are  very  liable  to 
be  removed  along  with  the  tooth,  in  the  extraction  of  the  latter. 

Elastic  fibres  do  not  occur  in  the  sclerotic  periosteal  mem- 
brane. The  nerve-branches  are  so  concealed  from  view  by  the 
fibrous  connective  tissue  that  they  cannot  be  identified  until  they 
are  cleared  up  by  treatment  with  the  proper  reagents.  The 
nerve-tubes  are  filled  with  a  mass  of  diminutive  fat-granules, 


GUMS.  279 

and  present  an  appearance  similar  to  that  found  in  senile  atrophy 
of  this  membrane.  Here  and  there,  the  bloodvessels  are  isolable 
in  short  segments  and,  in  places,  are  obliterated.  The  veins 
are  considerably  dilated  in  some  cases,  and  form  a  network 
with  large  meshes  (Atlas,  Fig.  122). 


Fig.  85. 


.=;  * 


»    ■  % 


I 


K  \"^^^  ^ 


Deposits  of  pigment  occur  in  the  callous  root-membranes  and 
may  be  seen  with  the  naked  eye  in  the  form  of  diffused  specks 
of  a  dark-brown  or  reddish-brown  color,  or  of  various  shades 
between  the  latter  and  a  grayish-black.  It  may  be  assumed, 
with  good  reason,  that  these  originate  from  previous  extrava- 
sations of  blood,  from  the  fact  that  blood-corpuscles,  deprived  of 
their  coloring  matter,  are  frequently  met  with  in  connection 
with  the  interposed  pigment  molecules. 

Gums. — Hypertrophy  of  the  gums  occurs  frequently  among 
the  sequelai  of  a  chronic  inflammatory  condition  of  the  root- 

*  Fig.  85. — Proliferation  of  the  stniight  connective  tissue  in  the  periosteum 
of  the  root  of  a  carious  upper  bicuspid.  Cross-section.  The  fibrilhited  bundles 
of  connective  tissue  encircle  the  root  of  the  tooih  in  more  or  less  parallel 
layers  («)  and,  also,  form  small  concentric  lamclUc  which  evidently  corres- 
pond to  the  proliferations  of  the  fibrous  sheaths  of  the  bloodvessels  and 
penetrate  more  or  less  deeply  into,  and  fill,  the  medullary  spaces  of  the 
upper  jaw  (b).  At  this  part  the  alveolar  wall  has  disappeared  under  resorp- 
tion and  the  lamelhe  of  the  spongy  tissue  of  the  bone  (c,  c)  have  been  dis- 
placed by  the  proliferating  connective  substance.  Witli  higher  magnifying 
powers,  the  familiar  erosions  resulting  from  resorption  may  be  seen  upon 
the  margins  of  the  bone.     Magnified  80  diameters. 


280  HYPERTROPHIES. 

membrane  following  caries  of  the  teeth,  and  is  induced,  also,  by 
the  irritation  of  the  gums  produced  by  the  products  of  the  de- 
generation of  the  hard  tissues  of  the  teeth.  The  sharp  edges  of 
stumps,  too,  -which  remain  after  the  destruction  of  the  coronal 
portions  and  necks  of  the  teeth,  become  the  sources  of  irritation. 

The  hypertrophy  occurs  both  in  the  papillary  portion  and, 
beneath  the  latter,  in  the  corium  of  the  mucous  membrane. 
When  it  occurs  in  the  former,  it  is  most  conspicuous  upon  the 
facial  surface  of  the  gums  and  is  confined  to  the  region  of  one 
tooth  or  a  few  teeth,  or  acquires  more  extended  limits  in  cases 
of  caries  involving  the  crowns  or  roots  of  several  teeth. 

While  the  papillre  occur  in  clusters  in  the  normal  state,  in 
the  hypertrophied  condition,  the  manner  in  which  they  are 
grouped  together  becomes  much  more  evident.  They  present 
smooth,  pale  or  reddish,  clavate,  conical  projections,  several 
millimetres  in  length  and  attached  to  a  common  stalk  ;  they 
are  confined  to  the  region  of  the  gum,  i.  e.,  they  extend  as  far 
as  the  alveolar  process  and,  consequently,  present  an  arched 
outline  when  viewed  together  (Atlas,  Fig.  118).  Frequently, 
the  hypertrophic  condition  becomes  less  marked  from  the  gin- 
gival border  towards  the  commencement  of  the  alveolar  process, 
while,  in  the  opposite  direction,  it  is  prolonged  into  the  intervals 
between  the  teeth  and  becomes  visible  upon  the  lingual  surface 
of  the  gum  in  the  form  of  tumid  protuberances  covered  with 
thick  epithelial  layers.  Papillary  proliferations,  in  the  earlier 
developmental  stages,  give  to  the  gums  a  velvety  appearance. 

Each  of  the  above-mentioned  conical  projections  is  composed 
of  a  group  of  hypertrophied  papillie  which  are  covered  by  nu- 
merous layers  of  flattened  epithelium  common  to  them  all,  and 
are  not  distinctly  visible  until  after  the  removal  of  the  latter. 
The  groups  are  separated  from  one  another  by  intervals  of 
varying  depth,  and  include  a  larger  (ten  to  fifteen)  or  smaller 
number  of  finger-shaped  papillie  which,  usually,  are  several  times 
larger  than  in  the  normal  condition  (Atlas,  Fig.  119).  Some 
of  the  hypertrophied  papillae  present  a  distended  appearance, 
with  an  irregular  outline,  others  lateral  or  terminal  excrescences 
or  buds,  which  indicate  a  continued  growth  ;  they  contain  in 
their  interior  a  continuous  vascular  loop ;  the  bloodvessels  in 


GUMS.  281 

them  frequently  pursue  an  irregular,  distinctly  wavy  or  spiral 
course,  divide  dichotomously  and  form  a  network ;  they  are 
considerably  dilated,  the  recurrent  capillaries  more  particularly, 
and  frequently  are  filled  with  a  homogeneous,  colloid  mass. 
Fine  elastic  fibres  occur  in  considerable  abundance.  If  marked 
cellular  infiltrations  into  the  corium  of  the  gums  occur,  they 
also  extend  into  the  papillte  and  along  the  capillaries.  The 
parenchyma  of  the  papillae,  in  consequence  of  nutritive  disturb- 
ances, sometimes  acquires  a  clouded  appearance,  has  a  dirty- 
brownish  color,  or  is  interspersed  with  numerous  fat-globules. 

The  epithelium,  also,  participates  in  the  hypertrophy  which 
affects  the  papillary  portion ;  the  nuclei  swell  up,  the  nucleoli 
become  more  prominent ;  occasionally  a  double  nucleus  is  met 
with.  The  groups  of  papillae  are  covered  by  the  cells  of  the 
horny  layer,  disposed  in  several  layers  common  to  them  all  and 
having  a  slightly  wavy  outline.  The  cells  of  the  mucous  layer, 
likewise,  are  increased  in  number ;  their  protoplasm  frequently 
presents  a  molecular  cloudiness ;  they  invest  the  individual 
papilU"e,  between  the  groups  of  which  they  form  conical  prolon- 
gations, extending,  in  many  cases,  to  a  considerable  depth  into 
the  corium. 

It  is  found,  also,  that  the  papillre  increase  in  length  and  thick- 
ness and,  also,  by  the  development  of  lateral  processes;  in  place 
of  a  simple  hypertrophy,  therefore,  there  succeeds  a  new-forma- 
tion of  papillae,  a  papilloma,  which,  in  its  general  form,  resem- 
bles the  acuminate  condyloma.  Contemporaneously  Avith  the 
growth  of  the  papilla,  the  bloodvessels,  also,  increase  in  length, 
become  wider  in  parts,  and  give  off  branches  by  means  of  which 
a  plexus  of  capillaries  is  formed.  The  nerves  do  not  appear  to 
participate  in  the  process.  As  the  dimensions  of  the  papillary 
portion  increase,  the  separate  laminae  of  epithelium,  also,  become 
augmented,  the  proliferation  of  the  cells  of  the  mucous  layer 
being  especially  notable.  The  development  of  the  latter  and 
that  of  the  papillee  take  place  in  opposite  directions,  namely, 
that  of  the  papillae  towards  the  free  outer  surface,  and  that  of 
the  cells  of  the  mucous  layer  towards  the  corium. 

The  hypertrophic  corium  of  the  gum  is  infiltrated  with  cells 
which  frequently  are  disposed  in  rows  and  in  part  accompany 


282  HYPERTROPHIES. 

the  bloodvessels  and  nerves  so  that  they  form  a  moshed  work, 
in  the  bi-ight  vacuities  of  which  connective-tissue  corpuscles, 
united  together  so  as  to  form  a  network,  are  visible  (Atlas, 
Fig.  119).  Moreover,  a  proliferation  of  ovoid  and  radiated 
elementary  organs  of  the  connective  tissue,  at  a  distance  fi-om 
the  bloodvessels  and  nerves,  is  also  observed.  These  cellular 
infiltrates  sometimes  are  so  extensive  as  neaidy  to  fill  the  corium 
layer  in  places,  and  to  occasion  a  notable  tumefaction  and  suc- 
culency.  These  products  of  proliferation,  as  well  as  the  former, 
of  a  higher  order  of  development,  frequently  undergo  retro- 
grade metamorphoses,  become  the  subject  of  fatty  degeneration, 
pigmentary  deposits,  shrinking,  colloid  degeneration,  the  latter 
being  presented  in  the  form  of  minute,  cloddy  masses.  In  the 
deepest  layers  of  the  mucous  membrane,  in  the  submucous  con- 
nective tissue,  quite  extensive  zones  of  ovoid  cells  are  often  met 
with,  or  even  groups  of  fat-cells,  though  I  have  never  observed 
any  very  marked  proliferation  of  the  latter;  here  also  are  found, 
occasionally  colloid  or  jelly-like  formations  and,  sometimes,  pig- 
mentary, brownish-yellow  masses. 

That  portion  of  the  hypertrophied  gum  which  extends  between 
the  teeth  sometimes  presents  a  lamellar  development,  with 
superposed,  enlarged,  papillary  elevations,  while  the  mucous 
layer  of  epithelium  dips  down  to  a  considerable  depth  between 
the  lamellEe. 

The  secretion  of  mucus  usually  is  increased  in  connection  with 
papillary  hypertrophy,  and  partial  exfoliations  of  the  epithelium 
occur,  leaving  superficial  erosions.  Bleeding  readily  occurs  from 
the  painless  swellings,  even  from  slight  mechanical  irritations. 

Sometimes  the  papillary  portion  is  not  involved  and  the  pro- 
liferation is  confined  to  the  corium,  occasioning  a  swellins;  of 
the  gum,  which  has  a  smooth  exterior.  In  these  cases,  which 
are  more  protracted,  the  cellular  infiltrations  give  rise  to  a  ten- 
dinous connective  tissue;  in  other  words,  the  hypertrophic  gum 
becomes  sclerosed,  and,  consequently,  it  presents  an  increased 
power  of  resistance  and  a  diminished  succulency.  Tlie  gradually 
obliterated  papillary  portion  is  covered  by  a  common,  thick, 
superficially  smooth  layer  of  epithelium.  Notwithstanding  the 
increased  consistence  of  the  corium,  cellular  infiltrates  are  met 


GUMS.  283 

■with  in  the  form  of  long  chain-like  rows  or  clusters  of  ovoid 
cells,  which  are  inclosed  within  a  capsule  of  fibrous  tissue.  Since 
the  periosteum,  also,  beneath  the  indurated  gum  is  tliickened, 
it  is  by  no  means  strange  that  cross-sections  of  the  latter  some- 
times present  slender  trabeculge  in  the  process  of  growth,  to- 
gether with  young  bone-corpuscles.  In  very  marked  callosities, 
such  as  are  presented  so  frequently  in  alveolar  cicatrices,  the 
tense  fibrous  tissue  contains  between  its  bundles  cells  which, 
for  the  most  part,  are  shrivelled  and  present  a  granular  cloudi- 
ness; the  obliterated  portions  are  indicated,  principally,  by  a 
speckled,  cloudy  appearance,  the  nerves  being  shrivelled  up  and 
the  bloodvessels  obliterated.  But,  even  in  cases  of  marked  in- 
duration, groups  of  well-formed,  apparently  vigorous  cells,  which 
still  retain  their  germinal  properties,  are  met  with. 


284  NEAV-FORMATIONS. 


y.  NEW- FORMATIONS. 

It  is  not  possible,  in  all  cases,  to  clraAV  a  line  between  new- 
formations  and  hypertrophies,  so  that  many  of  the  former  can 
only  be  described  as  localized  hypertrophies.  In  a  new-forma- 
tion, the  proliferation  originates  in  one  textural  portion  of  an 
organ  and  spreads  within  certain  limits,  displacing  more  or  less 
in  its  progress  the  normal  elements.  The  proliferating  tissue  is 
not  of  a  parasitic  nature,  that  is  to  say,  it  does  not  appropriate 
already  formed  tissues,  as  nutritive  material,  but,  rather,  induces 
reabsorption  of  them.  The  more  vigorous,  younger,  displaces  the 
older,  enervated  cell,  whether  it  is  a  homologous  or  heterolo- 
gous elementary  formation.  The  young  cells,  endowed  with  in- 
creased productivity,  supplant  the  old  ones.  A  new-forma- 
tion premises  an  increased  vitality  on  the  part  of  the  blood- 
vessels, together  with  proliferation  of  those  vessels  which  are 
destined  to  convey  nutriment  to  the  proliferating  organ.  The 
augmented  supply  of  blood  which  is  thereby  afforded  necessi- 
tates in  turn  an  increased  cell-formation  in  the  part  to  which  it 
is  distributed.  The  vascular  system  takes  a  prominent  part  in 
the  production  of  a  new-formation,  whether  the  connective  tissue, 
which  forms  the  framework  of  an  organ,  alone  participates,  or 
the  elementary  organs,  which  govern  the  function  of  an  organ, 
also  share  in  the  process.  The  tissue  of  the  organ  becomes  the 
subject  of  an  excessive  growth  within  the  affected  limits  and, 
also,  of  a  corresponding  alienation.  The  nervous  system  is  im- 
plicated only  secondarily  and,  in  exceptional  cases,  only,  appears 
to  take  a  prominent  part  in  the  process. 

New-formations  occur  in  the  hard  and  soft  tissues  of  the  teeth 
and  are  only  few  in  number,  while  the  contiguous  parts,  par- 
ticularly the  jaws,  present  a  very  great  variety,  a  knowledge  of 
which  comes  within  the  province  of  dentistry  and  is  necessary 
to  the  practical   dentist,  since    the    opportunity  is    frequently 


PULP.  285 

afforded  to  him,  first  of  all,  to  diagnosticate  them  and  to  give 
timely  advice  with  regard  to  operative  interference. 

Pulp. — New-formations  of  the  pulp  have  their  origin  either 
in  the  germs  of  the  connective  tissue  or  of  the  dentine.  The 
parenchyma  of  the  pulp  can  only  be  the  seat  of  an  increased 
productivity  when  there  is  sufficient  space  to  alloAv  the  necessary 
increase  in  volume;  such  a  condition  is  impossible  so  long  as 
the  pulp-cavity  remains  entirely  encompassed  by  dentine,  and 
can  only  occur  when  space  is  provided  by  the  destruction  of  a 
portion  of  the  wall  of  the  cavity. 

When  the  new^-formation  has  its  orio;in  in  the  dentinal  o;erms, 
the  circumstances  are  different ;  either  the  already-formed  den- 
tine or  the  pulp-tissue  becomes  displaced,  and  is  replaced  by  a 
newly  formed  hard  structure. 

If  caries  has  destroyed  a  portion  of  the  wall  of  the  pulp-cavity 
and  the  corresponding  segment  of  the  pulp  is  denuded ;  if  the 
individual  is  young  in  age;  if  the  irritation  of  the  pulp  is  mod- 
erate in  character  and  there  is  no  purulent  destruction;  if, 
besides,  the  local  relations  of  the  carious  tooth  and  the  locality 
of  the  caries  in  the  tooth  itself  are  such  that  the  proliferating 
substance  is  protected  against  mechanical  injuries,  there  arises 
upon  the  pulp,  and  projecting  more  or  less  beyond  the  perforated 
carious  portion,  a  soft  secondary  formation  with  a  rounded  outer 
surface  which  is  covered,  frequently,  with  a  layer  of  muco-puru- 
lent  matter.  Such  a  formation,  usually,  is  described  as  a  polypus 
of  the  pulp. 

The  new  structure  may  acquire  about  the  size  of  a  small  pea, 
sometimes  has  a  bluish-red  color,  at  others  is  flesh-colored ;  it 
is  of  a  spongy  or  fleshy  consistence,  not  sensitive  to  the  touch, 
nor  Avhen  slightly  pricked,  and  is  organically  united  with  the 
coronal  and  radical  portions  of  the  pulp.  It  contains  an  abun- 
dance of  roundish  and  spindle-shaped  cells,  the  bodies  of  the 
cells  varying  slightly  in  extent,  which,  together  with  a  small 
amount  of  fibrous  intercellular  substance,  compose  the  principal 
portion  of  the  tumor  (Atlas,  Fig.  79).  The  groups  of  cells 
are  in  long  rows  and  have  a  radiated  arrangement.  The  cells, 
which  are  provided  with  processes,  unite  here  and  there  to  form 
a  network ;  rows  of  spindle-shaped  cells,  also,  are  met  with.     The 


286  NEAV-FORMATIONS. 

bloodvessels  pursue  a  tortuous  course  from  the  interior  towards 
the  periphery,  are  numerous,  comparatively  large,  and  invested 
•with  thick,  fibrous  sheaths.  The  type  presented  by  the  capil- 
lary ramifications  is  different  from  that  found  in  the  pulp. 
Nerves  or  remains  of  the  parenchyma  of  the  pulp"  are  not  to  be 
seen.  I  have  never  observed  an  epithelial  covering  upon  the 
outer  surface.  Occasionally,  a  purulent  infiltration  occurs  in 
the  vicinity  of  the  latter  and  the  bloodvessels  extend  quite  near 
to  it,  so  that  hemorrhage  is  easily  produced. 

The  parenchymatous  connective  tissue  is  the  seat  of  the  pro- 
liferation described  as  sarcoma  of  the  pulp,  in  Avhich  the  paren- 
chyma gradually  is  destroyed,  as  is  indicated  by  the  absence  of 
nerves  and  the  altered  character  of  the  bloodvessels.  As  the 
sarcoma  is  located  upon  the  outside  of  the  remains  of  the  pulp, 
it  serves  in  a  measure  to  protect  the  latter.* 

New-formations  of  tub  Hard  Tissues  of  the  Teeth. — 
These  Avere  first  recognized  by  the  anatomists  of  the  previous 
century,  and  have  occupied  the  attention  of  dentists  and  patho- 
logical anatomists  of  recent  times.  Of  late  years,  manifold  con- 
troversial opinions  have  arisen  respecting  their  clinical  signifi- 
cation and  importance. f 

*  Salter  (Des  pulpo-dontaires,  Archives  Generales,  1857)  distinguishes  two 
classes:  1.  Hypertrophy  of  the  pulp  in  which  there  is  no  chiinge  in  the  tex- 
ture, which  retains  its  normal  sensibility  and,  occasionally,  is  the  seat  of 
pain.  This  he  never  found  in  carious  teeth  and  only  in  connection  with 
fractures.  Tliis  class  obviously  does  not  belong  to  the  sarcomata  (polypi), 
but  rather  to  the  cicatricial  formations.  2.  In  this  class  the  tumor  is  not 
sensitive  and  occurs  in  connection  with  caries  in  the  teeth  of  young  persons, 
generally  in  the  molars  of  young,  weakly  females.  In  two  cases,  the  tumor 
acquired  quite  large  dimensions  and  corresponded  histologicalh^  with  the 
gum  ;  superficially  there  was  a  thick  layer  of  polygonal  epithelial  cells,  be- 
neath which  were  small,  irregular  papilh«  Indeed,  both  of  these  cases 
might  easily  have  been  confounded  with  a  tumor  of  the  gum. 

f  J.  Hunter  (Nat.  History  of  the  Teeth)  devotes  a  special  paragraph  to 
these,  in  which  it  is  shown  that,  in  teeth  which  are  worn  away  by  attrition, 
that  portion  of  the  pulp-cavity,  adjacent  to  the  abraded  surface,  becomes 
filled  with  a  new  substance  which  occupies  the  centre  of  the  abraded  sur- 
face and,  generally,  is  softer  than  the  rest  of  the  tissue  of  the  tooth.  Pro- 
chaskiif  (Adnotat.  academ.  Prag.  1780)  treated  of  the  same  subject  in  his 
ohservat.  anatom.  do  decremento  dentium  corp.  humani.  Oudet  (Diction- 
naire  de  m^decine,  article  dent.,  1835),  gives  a  good  description  of  these  new- 


NE^y -FORMATIONS    OF    HARD    TISSUES    OF    TEETH.  287 

A  new-formation  of  the  hard  tissues  of  the  tooth  cannot  be 
produced  except  from  their  formative  elements,  and  since  those 
of  the  enamel  wholly  disappear  when  the  formation  of  the  crown 
of  the  tooth  is  completed,  it  follows  that  the  new-formations  are 
limited  to  those  of  dentine  and  of  bony  substance.  In  these 
new-formations,  the  dentinal  cells  play  the  principal  part,  as  in 
the  formation  of  ordinary  dentine,  while  an  accessory  or  inde- 
pendent new-formation  of  bony  substance  alone  is  produced 
from  the  connective  tissue  of  the  parenchyma  of  the  pulp  through 
the  medium  of  its  bloodvessels. 

The  new-formations  which  are  to  be  taken  into  consideration, 
are  located  upon  that  surface  of  the  body  or  root  portion  of  the 
pulp  which  is  directed  towards  the  already-formed  dentine, 
in  the  parenchyma  of  the  pulp,  or  are  imbedde'd  in  the  sub- 
stance of  the  dentine.  Hence,  many  varieties  may  be  distin- 
guished. According  to  their  situation  they  are  parietal,  ad- 
formations,  which  he  divides  into  two  classes,  the  adherent  and  unattached. 
He  paid  no  attention  to  their  histological  structure  ;  their  connection  with 
the  pain  in  many  of  the  cases  cited  may  be  doubted.  Other  writers  {vide 
E.  Hohl's  Monographic  iiber  Neubildungen  der  Zahnpulpe,  1868),  as  Rous- 
seau, Nasmyth,  Bertin,  Raschkow,  and  Ryding,  met  with  these  hard  forma- 
tions both  in  human  teeth  and  in  those  of  animals.  R.  Owen  (Odontog- 
raphy) illustrates  numerous  new-formations  of  osteo-dentine,  but  does  not 
go  very  deeply  into  the  subject.  Salter  (Guy's  Hospital  Reports,  ix)  treats 
of  osteo-dentinal  formations  in  addition  to  simple  calcifications  of  the  pulp, 
calcareous  granular  deposits.  He  regards  them  as  the  result  of  a  pathologi- 
cal process.  We  are  indebted  to  .J.  Tomes  (A  Course  of  Lectures  on  Dental 
Phys.  and  Surgery,  1848)  for  their  first  minute  anatomical  description,  and 
to  F.  Ulrich  (Zeitschrift  der  K  K.  Gesellschaft  der  Aezte  zu  Wien,  1851), 
who  distinguishes  in  them  two  kinds  of  tissues,  a  dentinoid,  an  osteoid,  and 
a  combination  of  the  two.  Wedl  (Grundziige  der  pathol.  Histologie,  1854), 
Heider  and  Wedl  (Deutsche  V^ierteljahrsschr.  f.  Zahnheilk.,  1864),  give  fur- 
ther anatomical  details,  and  the  latter  endeavor  to  determine  the  mode  of 
development  of  these  new-formations.  R.  Hohl,  in  the  work  cited  above, 
furnishes  a  critical  treatise  (1868),  based  upon  independent  investigations, 
and  applies  to  these  formations,  the  terms  odontoma,  osteoma,  and  osteo- 
odontoma.  Many  writers  have  described  the  dentinal  new-formations  as 
odontomata,  but  since  this  term  has  been  selected  to  designate  certain  dental 
malformations,  it  is  inadmissible  to  apply  it  to  a  new-formation  of  dentine, 
and,  therefore,  a  distinction  must  be  made  between  the  odontomata  occurring 
before  and  after  the  completion  of  the  development  of  the  tooth,  namely, 
odontoma  congenitum  and  acquisitum. 


288  NEW-FORMATIONS. 

lierent  to  the  Avail  of  tlic  pulp-cavity,  or  external ;  free  or  in- 
ternal; and  interstitial  or  imbedded  in  the  dentine;  according 
to  their  number  they  are  single  or  multiple;  in  form  they  are 
flattened,  round,  wedge-shaped,  conical,  berry-like,  warty,  at- 
tached by  means  of  a  pedicle  to  the  wall  of  the  pulp-cavity; 
with  respect  to  their  position,  they  are  located  upon  the  wall  of 
the  pulp-cavity  towards  the  masticating  surface,  upon  its  radical 
or  lateral  wall,  and  fill,  more  or  less,  the  pulp-cavity  or  root- 
canal;  with  reference  to  the  period  at  which  they  are  developed, 
they  may  be  premature  or  senile;  in  respect  of  their  origin, 
they  are  consecutive,  engendered  by  external  causes  or  sponta- 
neous, and  in  size,  they  are  very  small,  or  may  fill  nearly  the 
entire  pulp-cavity  or  root  canal. 

A  fine  specimen  of  new-formation  of  dentine  in  the  pulp-cavity 
or  root-canal  presents  to  the  naked  eye  a  yellowish,  amber  color, 
a  certain  degree  of  transparency,  and  a  hardness  nearly  equal  to 
that  of  dentine.  The  exterior,  invested  by  the  pulp-tissue,  always 
has  a  rounded  outline  and,  generally,  is  nodulated. 

Their  structure  varies  according  to  the  circumstances  under 
which  they  are  developed.  If,  from  a  new-formation  of  dentine 
which  has  arisen  subsequently  to  the  abrasion  of  the  crown  and 
is  perceptible  upon  the  abraded  surface  as  a  central  spot  sur- 
rounded by  polished  dentine,  sections  through  the  middle  por- 
tion, perpendicular  to  the  abraded  surface,  be  examined,  it  will 
be  found  that  the  new  hard  substance  is  more  transparent  than 
the  original  dentine,  that  the  new  canals  extend  in  a  radiated 
manner  towards  the  old  and  preserve,  essentially,  the  same  di- 
rections as  if  they  were  central  prolongations  of  the  latter.  In 
most  places,  there  is  observed  proportionately  rapid  diminution 
in  their  transverse  diameters,  and  an  insertion  of  their  twig-like 
continuations  between  the  old,  wide  canals;  in  many  places, 
therefore,  there  is  no  communication  between  the  respective 
canals,  while  in  others  an  immediate  transition  of  the  new  into 
the  old  canals  may  be  identified.  From  these  facts  it  is  evident 
that,  in  these  cases,  there  occurs  a  continued  development  of  den- 
tine within  certain  limits  determined  by  an  irritation,  and  that 
the  new  layers  are  deposited  in  immediate  contiguity  with  the 
old  and,   in  parts,  arc  intimately  and  organically  united  with 


NEW-  FORMATIONS    OF    HARD    TISSUES    OF    TEETH.        289 

the  latter.  Dentine  of  this  description,  which  serves  as  a  pro- 
tective covering  of  the  pulp,  is  called  dentine  of  repair,  sec- 
ondary dentine  (Ersatzdentin),  as  is  that  dentine,  also,  which  is 
formed  in  cases  of  chronic  caries  upon  that  portion  of  the  Avail 
of  the  pulp-cavity  corresponding  to  the  carious  locality  and 
projects  into  the  carious  cavity  in  the  form  of  a  spherical  seg- 
ment. In  the  latter  cases,  also,  we  find  that  the  new  dentinal 
canals  are  continuous  with  the  old;  there  is,  usually,  an  abundant 
basis-substance,  and  the  canals  are  separated  by  quite  wide  in- 
tervals. Frequently  there  is  a  want  of  uniformity  in  develop- 
ment; for  instance,  the  continuity  of  the  dentinal  substiince  is 
interrupted  by  small  and  quite  large,  elongated,  jogged  cavities 
which  are  filled  with  amorphous  calcareous  salts.  Some  of 
these  are  the  results  of  resorption,  similar  to  those  observed  fre- 
quently'^ in  senile  dentine,  and  others  are  interglobular  spaces 
(Atlas,  Fig.  72).  The  less  compact  structure  of  the  new  den- 
tine is  due  to  these. 

A  different  structure  is  presented  by  the  concentrically  lami- 
nated forms,  two  varieties  of  which  are  distinguished,  the  simple 
and  comjjlex.  These  correspond,  in  some  respects,  with  the 
nodular  calcifications  described  by  Salter.  These  new-forma- 
tions of  dentine,  especially  if  tl»ey  are  quite  small,  are  liable  to 
be  confounded  with  simple  calcifications.  The  latter,  however, 
occur  as  discrete,  roundish  bodies  in  the  parenchyma  of  the 
pulp,  and  never  as  confluent,  very  large  grains,  and,  also,  are 
met  with,  especially  in  the  pulp  of  the  root,  in  the  form  of 
needle-shaped,  resistant  bodies.  A  detailed  description  of  them 
has  been  given,  already,  in  connection  with  atrophies. 

Thin  cross-sections  of  these  new-formations  present  a  central 
basis-substance,  composed,  in  many  cases  at  least,  of  transparent, 
discoid,  homogeneous,  structureless,  nucleus-like  masses,  either 
single,  in  pairs,  or  in  large  numbers  (Atlas,  Fig.  58),  around 
which  concentric  layers  are  disposed  in  a  manner  similar  to 
those  around  the  Haversian  canals  in  bone.  The  central  sub- 
stance not  infrequently  contains  globular  masses  and  small  in- 
terglobular spaces.  If  the  basis-substance  is  unusually  abundant, 
a  very  delicate,  retiform,  structure  may  sometimes  be  distin- 
guished with  a  high  magnifying  power  and  suitable  light.     By 

19 


290  NEW -FORMATIONS. 

means  of  very  careful  and  sliglit  corrosion,  the  concentric  and 
concentrically-disposed  radiated  layers  are  brought  distinctly 
into  view.  Here  and  there,  cloudy  spots,  together  with  molec- 
ular' degeneration  of  the  substance,  presenting  a  gray  or  dirty- 
yellowish  color,  are  observed. 

The  canals  of  the  concentric  dentinal  new-formations  have  a 
centripetal  course,  i.  e.,  they  converge  from  the  periphery  towards 
the  centre  (Atlas,  Fig.  65).  As  a  rule,  they  are  shorter  than  in 
normal  dentine,  and,  therefore,  their  diameters  diminish  more 
rapidly  ;  they  deviate,  frequently,  from  a  direct  course,  branch 
without  uniformity  and  often  terminate  in  a  tuft  of  twig-like 
branches.  On  account  of  the  irregularity  in  which  they  run, 
the  intervals  between  them  are  variable;  when  there  are  globular 
masses  present,  they  terminate  at  the  centre  in  the  interglobular 
spaces.  Anastomotic  loops  are  met  with,  frequently,  particularly 
in  the  complex  forms. 

From  the  facts  which  have  been  stated  above,  it  is  apparent, 
since  the  existence  of  dentinal  canals  implies  the  pre-existence 
of  dentinal  cells,  that  the  latter  must  have  acquired  a  circular 
arrangement  at  the  time  of  the  formation  of  the  new  growth, 
and  that,  as  their  proliferation  progressed,  they  became  separated 
from  each  other  by  larger  intervals  and,  also,  suffered  deviations 
in  the  direction  of  their  development. 

]S^ot  infrequently  the  canals  are  filled  Avith  grains,  arranged 
like  a  string  of  pearls,  or  imbued  with  the  coloring  matter  of 
the  blood,  probably  in  consequence  of  extravasations  of  blood 
or  of  inflammatory  processes  in  the  Surrounding  soft  tissues. 
Erosions  from  resorption  are  observed,  occasionally,  upon  the 
periphery  of  the  new-formation  which  is  surrounded  by  the 
atrophic  pulp,  and  indicate  a  reaction  on  the  part  of  the  still 
vital  pulp.  There  can  be  no  doubt,  therefore,  that  these  new- 
formations  are  closely  connected  with  morbid  processes  in  the 
persisting,  though  to  be  sure,  in  many  cases,  scanty  remains  of 
the  pulp. 

Such  a  probability  is  strengthened  by  the  anatomical  exami- 
nation of  these  remains.  Even  though  one  portion  of  the  pulp, 
which  becomes  reduced,  frequently,  to  a  thin  membrane,  has  ac- 
quired a  tendinous  character  or  undergone  a  net-like  atrophy, 


NEW- FORMATIONS    OF    HARD    TISSUES    OF    TEETH.       291 

another  portion  may  still  be  traversed  by  well-preserved  vessels 
containing  fresh  blood,  and  even  bundles  of  nerve-fibres  of 
normal  appearance  occur,  which  are  still  capable  of  transmitting 
sensations  of  pain.  In  many  cases,  it  is  true,  these  remains  are 
totally  obliterated. 

When  the  parietal,  nodulated  new-formations  are  organicaUy 
united  to  the  old  dentine,  a  dividing  layer  is  present,  commonly, 
which  usually  has  a  light  color  and  is  perceptible  to  the  naked 
eye,  since  the  bounding  layer  of  the  old  dentine  is  distinguished 
by  the  uniform  appearance  presented  by  the  canals  extending 
from  it,  while  the  canals  of  the  new-formation  meet  those  of  the 
old  dentine  generally  at  an  acute  angle  and,  here  and  there,  at 
nearly  right  angles;  the  latter  rectangular  diversion  of  the 
canals  is  most  marked  in  many  of  the  larger  adherent  new- 
formations  (Atlas,  Figs.  61  and  G2).  Globular  masses  with 
opaque  interglobular  spaces  are  observed,  here  and  there,  in 
these  transitional  zones.  In  general,  it  may  be  stated  that  in 
secondary  dentine  following  caries  or  abrasion  of  the  teeth,  the 
direction  of  the  dentinal  canals  will  be  found  to  correspond 
with  that  of  the  canals  of  the  old  dentine,  while  in  the  parietal, 
concentrically  laminated,  nodulated  new-formations,  there  is  no 
correspondence  in  the  direction  of  the  respective  canals. 

The  periphery  of  the  concentric  new- formations  usually  pre- 
sents deep  channels  containing  a  varying  number  of  bloodvessels 
(Atlas,  Fig.  57),  which,  however,  do  not  completely  fill  the 
cavities.  Sometimes  the  coloring-matter  of  the  blood  is  still 
perceptible  and  Avell  preserved,  and  a  corresponding  reddish 
color  of  the  dentinal  canals,  also,  is  observed  ;  generally,  how- 
ever, the  coloring-matter  is  changed  to  a  dirty  yellow,  yellowish- 
brown,  or  to  the  different  shades  between  this  and  a  dark-brown. 
The  wider  channels  are  filled,  more  or  less,  with  atrophic  reti- 
form  connective  tissue  in  which  the  cavities  of  one  or  more  blood- 
vessels with  their  sanguineous  contents  are  perceptible.  They 
vary  in  diameter,  occasionally  branch  and,  particularly  in  the 
complex  forms,  several  even  unite  and  form  a  sort  of  network. 
They  frequentl}"^  undergo  calcification,  in  which  cases  the  cal- 
careous particles  in  mutual  contact  compose  the  peripheral 
portion  of  their  contents.     Frequently  they  are  surrounded  by 


292  NEW -FORMATIONS. 

an  accessory  Inyev  of  varying  thickness  and  with  an  indented 
surface  towards  the  new-formation,  in  the  fohls  of  which  a  cel- 
luhir  body  may,  perhaps,  be  found,  here  and  there,  and  I  have 
even  met  Avith  well-formed,  multiradiated,  bone-corpuscles  in 
them,  so  that  it  can  be  said  that  an  osteoid  mass  is  developed 
around  the  bloodvessels. 

It  may  be  assumed  with  reason,  that  the  above-mentioned 
bloodvessels  are  derived  from  those  of  the  pulp,  contemporane- 
ously with  a  connective  tissue  which  has  a  tendency  to  ossifica- 
tion (Atlas,  Fig.  59). 

These  channels,  which  often  are  replete  Avith  calcareous  salts 
and  frequently  contain  bloodvessels,  must  not  be  confounded 
with  the  usually  smaller,  but  occasionally  more  extensive, 
irregular  cavities  which,  as  shown  above,  occur  in  the  central 
portions  of  the  new-formations,  and  in  which  the  canals  fre- 
quently terminate.  I  have  met  with  a  few  cases  only  of  true 
neiv-formations  of  osseous  substance  within  the  parenchyma  of 
the  pulp.  They  occurred  in  the  pulps  of  milk  teeth  which  were 
undergoing  resorption,  and  one  of  these  cases  is  reported  in  the 
above-cited  communications  by  Heider  and  Wedl.  Upon  the 
posterior  surface  of  a  milk  incisor  which  was  extracted,  there 
was  a  deeply-grooved  breach  of  substance,  about  six  millimetres 
in  len<2;th,  extending  from  the  neck  of  the  tooth  towards  the 
root,  and  the  corresponding  portion  of  the  coronal  and  radical 
pulp  was  denuded.  The  contents  of  the  nerve-tubes  of  the 
latter  had  undergone  a  molecular  degeneration,  and  the  nerve- 
tubes  themselves  presented  in  places  a  shrivelled  appearance. 
Within  the  pulp,  which  was  tinged  with  blood,  a  firm  lamella 
was  found  united  with  the  tissue  of  the  pulp,  about  two  milli- 
metres in  length  and  one  millimetre  in  breadth.  Upon  very 
close  examination  of  the  structure,  it  was  found  that  the  central, 
more  compact  portion  was  ossified,  while  the  marginal  portion 
was  composed  of  aggregations  of  minute  calcareous  grains. 
The  lamella  contained,  as  is  the  case,  generally,  with  young, 
osseous  plates,  several  oval,  sharply-cut  foramina  for  the  trans- 
mission of  bloodvessels;  very  distinct  bone-corpuscles,  which 
were  in  clusters,  were  furnished  with  short  processes  and,  on 
the  whole,  bore  a  strong  resemblance  to  those  of  a  young  for- 


NE\y- FORMATIONS    OF    HARD    TISSUES    OF    TEETH.      293 

mation.  The  new-formation  of  osseous  substance,  in  tliis  case, 
was  due  to  the  irritated  condition  of  the  pulp,  engendered  by 
its  exposure. 

The  greater  portion  of  the  very  common  osteo-dentinal  for- 
mations is  composed  of  dentine ;  the  bony  substance  occurs  in 
very  small  quantity,  and  may  consist  merely  of  a  group  of  a 
few  bone-corpnscles.  The  osseous  substance  not  infrequently 
attains  only  a  rudimentary  development  and  resembles  that 
which  occurs  upon  the  cement  towards  the  neck  of  the  tooth. 
It  has  been  stated  that  bone-corpuscles  sometimes  make  their 
appearance  in  the  peripheral  layer  of  the  bloodvessels  which 
have  penetrated  the  new-formation  ;  they  are  also  met  with, 
however,  either  towards  the  periphery  of  the  new-formation, 
where  they  occur  in  groups  (Atlas,  Fig.  69)  and  are  separated 
from  the  new  dentine  by  globular  masses,  or  they  occur  in  the 
central  portion  of  the  new-formation.  Cases  in  which  the  cen- 
tral portion  of  the  new-formation  is  occupied  by  an  extensive 
mass  of  osseous  substance  are  quite  rare  and,  apparently,  occur 
only  when  the  formation  acquires  unusually  large  dimensions 
and  presents  a  regularity  in  its  development.  In  such  cases, 
too,  vascular  canals  are  present  in  the  bony  tissue.  A  very  fine 
illustration  of  a  case  of  this  kind  is  given  in  "  Wedl's  Patho- 
logical Histology,"  Fig.  141  B,  where  the  formation  is  attached 
to  the  wall  of  the  dental  canal  of  a  bicuspid  and  is  oval  in  shape, 
its  long  diameter  measuring  five  millimetres  ;  it  presents  a  pe- 
ripheral dentinal  tissue,  nearly  a  millimetre  in  thickness,  which 
forms  an  annular  investment  to  the  central  osteoid  tissue. 

In  these  new- formations,  both  the  bony  and  the  dentinal  tissues 
experience  frequent  interruptions  in  their  development,  as  is  in- 
dicated by  the  frequent  occurrence  of  irregular,  jagged  cavities 
in  the  new  dentine,  and  by  the  variable  or  dwarfish  forms  and 
the  irregular  disposition  of  the  bone-corpuscles. 

Many  of  the  parietal  new- formations  of  dentine  or  osteo-den- 
tine,  which  are  firmly  adherent  to  the  wall  of  the  pulp-cavity  or 
root-canal,  displace  more  or  less  of  the  original  dentine  at  the 
points  of  attachment,  so  that  shallow  depressions  are  perceptible 
upon  the  walls  after  the  removal  of  the  new-formations  ;  a  par- 
tial resorption,  therefore,  must  have  taken  place  at  these  points. 


294  NEW -FORMATIONS. 

Not  infrequently,  also,  new-formations  arc  intercalated  in  the 
original  dentine  and  are  then  distinguished  as  interstitial.  They 
are,  commonly,  multiple  and,  according  to  my  experience,  almost 
always  occur  in  the  roots  of  the  molars.  Fig.  Qi^  in  the  Atlas 
illustrates  such  a  formation,  and  Figs.  G3  and  64,  also,  afford  a 
very  good  general  view  of  them.  They  are  met  with,  sometimes, 
in  close  proximity  to  the  cement.  Their  structure  always  pre- 
sents the  same  type,  viz.,  tlieir  canals  have  a  centripetal  course 
and  open  in  central,  larger  or  smaller,  cavities  resembling  bone- 
corpuscles,  and  in  interglobular  spaces  when  there  are  globular 
masses  present.  Not  infrequently,  ramifying,  vascular  canals 
traverse  the  multiple  formation  and  unite  to  form  a  network. 
Each  of  the  formations  has  its  own  sj^stem  of  dentinal  canals 
which  are  invested  by,  and  decussate  freely  with,  the  canals  of 
the  original  dentine  without,  however,  entering  into  direct  com- 
munication with  the  latter.  Just  as  in  the  preceding  pages,  in 
connection  with  hypertrophy  of  the  cement,  we  assumed  an  in- 
terstitial growth  of  bone,  so,  in  the  present  case,  we  have  to  as- 
sume the  occurrence  of  an  interstitial  dentinal  development. 

The  conditions  of  the  occurrence  of  the  latter  remain  unde- 
termined with  our  still  defective  knowledge  concerning  the  life 
of  the  teeth  in  general,  and  of  the  dentinal  cells  in  particular  ; 
this  much,  however,  is  established,  that  resorption  o£  the  original 
dentine  is  brought  about  by  the  interposition  of  the  new,  and  it 
is  very  probable,  that  the  bloodvessels  which,  by  their  growth 
from  the  root-pulp,  penetrate  the  d^itine  (Atlas,  Figs.  59,  97, 
and  98),  have  a  definite  connection  with,  and  are  the  medium 
through  which,  on  the  one  hand,  the  resorption,  and  on  the 
other,  the  new-formation  is  accomplished.  We  see,  first  of  all, 
a  canal  containing  a  bloodvessel  which  mav  be  traced  to  its 
origin  in  the  root  portion  of  the  pulp.  Accompanying  these  are 
spheroidal,  transparent,  sharplj^-defined  masses,  presenting  a 
lobulated  appearance  from  their  mutual  apposition,  and  con- 
taining a  minutely  granular  matter  which  presents,  in  more  ex- 
tensive masses,  a  structure  of  radiated  concentric  laminte;  these 
are  to  be  regarded  as  the  rudiments  of  an  osteoid  substance, 
and  all  the  more  so  from  the  fact  that  the  vascular  canals,  now 
and  then,  are  surrounded  in  places  by  globular  masses  merely, 


NEW- FORMATIONS    OF    HARD    TISSUES    OF    TEETH.      295 

and  at  otlier  times  are  found  to  be  invested  by  an  accessory, 
well-developed  bony  tissue  with  an  indented,  sharply  defined 
margin  directed  towards  the  dentine.  There  occurs,  then,  an 
excentric  development  of  the  pulp-vessels  and  dentinal  cells  ; 
the  new,  more  vigorous  tissue  displaces  the  old;  the  proliferating, 
fresh  dentinal  cells  occupy  the  place  of  the  dentine  as  the  latter 
gradually  undergoes  resorption. 

On  the  other  hand,  isolated,  either  single  or  multiple,  den- 
tinal and  osteo-dentinal  formations  are  met  with  in  the  substance 
of  the  pulp,  having  a  diameter  of  from  one  to  several  millime- 
tres, and  a  rounded,  frequently  lobulated  form  (Atlas,  Figs,  57 
and  68).  With  regard  to  the  development  of  these  isolated,  en- 
cysted new-formations,  Ileider  and  I,  in  the  communications 
cited  above,  have  maintained  the  view  of  the  occurrence  of  an 
inversion  of  the  layer  of  dentinal  cells,  and  upon  the  following 
grounds:  1.  The  dentinal  canals  pursue  a  centripetal  course  ; 
therefore,  the  dentinal  cells,  which  enter  into  the  formation  of 
the  latter  and  the  development  of  which  proceeds" from  the  pe- 
riphery of  the  inverted  portion  (Einbuchtung)  towards  the  centre, 
must  have  assumed  an  adequate  arrangement ;  2.  With  multiple, 
encysted  new-formations,  we  observed  stelliform  groups  of  den- 
tinal cells  which  we  interpreted  as  the  primary  stage  of  the  in- 
verting process  (Insinuation) ;  3.  An  inversion  of  a  group  of 
dentinal  cells  and  their  detachment  corresponds,  also,  to  physio- 
logical processes,  e.  g.,  to  the  formation  of  the  vesicles  of  the 
thyroid  gland  or  ovarian  follicles.  Obviously,  the  inversion  in- 
cludes, at  first,  a  verj  minute  space  which  becomes  filled  with 
new  dentine;  as  the  proliferation  of  the  radiated  groups  of  den- 
tinal cells  progresses,  new  layers  of  dentine  continue  to  be 
formed  in  the  mass  until  the  final  separation  occui's.  The  den- 
tinal cells  upon  the  periphery  of  the  new-formations  do  not  ad- 
mit of  direct  identification,  when  the  growth  of  the  latter  has 
ceased  and  they  are  invested  by  an  atrophic  tissue.* 

*  E.  Hohl  (liber  Neubildiingen  der  Zahnpulpc  uiid  Doutsehe  Yiertelj.  f. 
Ziihnheilkuiide,  1868)  does  not  accept  this  simple  interpretation,  and  says, 
if  this  be  the  correct  view,  then  we  ought  to  find  a  sort  of  pedicle  in  every 
case,  but  he  has  never  seen  anything  of  the  kind.  New-formations  are  met 
with,  however,  indeed,  they  are  by  no  means  of  rare  occurrence,  which  are 


296  NEAV-FOKMATIONS. 

A  ncio-formadon  of  enamel  cannot  occur  after  the  develop- 
ment of  the  enamel-cap  is  completed.  Hence,  in  the  combination 
illustrated  in  the  Atlas,  Fig.  69,  it  is  not  to  be  considered  that 
the  osteo-dentine  and  conical  process  of  enamel,  together,  com- 
pose a  new-formation ;  the  pear-shaped,  sharply  defined  cone  of 
enamel,  which  encroaches  upon  one  side  of  a  truncated  conical 
prolongation  of  the  new-formation  and  is  invested  by  an  annular 
layer  of  radiating  dentinal  canals,  is  the  result  of  an  anomaly 
in  the  development  of  an  upper  Avisdom  tooth,  and  an  organic 
union  has  taken  place  between  the  new-formation  of  osteo-den- 
tine and  the  dentinal  layer  which  invests  the  cone  of  enamel. 

The  combination  ivitli  calcifications,  especially  in  the  smaller 
varieties  of  new-formations,  is  met  with,  sometimes,  where  the 
dentinal  canals  are  very  few  in  number,  while  the  remaining 
portion  presents  concentrically  disposed  radiated  laminae,  or  a 
minutely  reticulated,  calcified  mass  and,  consequently,  the  con- 
cretion or,  in  other  words,  the  calcification  of  the  organic  basis- 
substance  of  the  new  dentine  apparently  predominates.  The 
calcareous  grains,  as  is  the  case  in  atrophic  pulps  (Atlas,  Fig. 
46),  are  true  concrements  and  occur,  also,  as  accessory  products 
in  connection  with  hard  new-formations,  but  never  enter  into 
organic  union  with  the  original  dentine;  they  are  located  within 
the  parenchyma  of  the  pulp  and  are  calcifications  in  the  con- 
nective tissue.  In  general,  it  may  be  stated  that  all  those  pro- 
cesses which  ensue  in  connection  with  atrophy,  such  as  pigmental 
degeneration,  obliterations,  scleroses,  accumulations  of  colloid 
masses  within  and  outside  of  the  vascular  system,  &c.,  occur 
also  in  pulps  containing  hard  new-formations. 

attached  to  the  original  dentine  by  moans  of  a  pedicle  (Atlas,  yig.  54),  and 
in  cases  where  there  is  no  connection  by  a  pedicle,  detachment  has  ensued. 
With  regard  to  the  character  of  the  tissue  within  the  fold,  we  have  expressed 
a  decided  opinion,  namely,  that  it  is  new  dentine.  Hohl  finds  it  necessary 
to  have  recourse  to  a  new  formation  of  dentinal  cells  in  the  midst  of  the 
pulp-tissue  and,  with  this  idea,  conceives  that  the  pulp-cells  give  oft' processes 
towards  the  centre,  which  participate  in  the  new-formation.  The  occur- 
rence of  such  a  transformation  of  a  pulp  into  a  dentinal  cell,  however,  does 
not  harmonize  with  the  views  entertained  at  the  present  day,  with  regard  to 
the  development  of  the  dentine.  The  dentinal  cells,  according  to  Hohl, 
acquire  a  roundish  form,  with  the  increasing  age  of  the  individual,  an  asser- 
tion, however,  which  I  am  unable  to  confirm. 


NEW- FORMATIONS    OF    HARD    TISSUES    OF    TEETH.       297 

Ulrich  and  J.  Tomes  called  attention  to  the  fact,  which  has 
been  confirmed  by  many,  that  hard  new-formations  are  of  fre- 
quent occurrence  in  the  much  worn  teeth  of  elderly  persons, 
and  that  no  distinction  can  be  made  as  to  their  more  frequent 
occurrence  in  the  incisors,  canines,  bicuspids,  or  molars.  With 
many  individuals  there  exists  a  predisposition  (Diathesis)  to  the 
development  of  these  new-formations,  since  they  are  found  in 
several  teeth  in  very  great  abundance.  Finally,  even  the  sound 
teeth  of  childi'en  are  not  exempt.  The  milk  teeth,  which  enter 
upon  a  stage  of  senescence  towards  the  period  of  dcdentition,  not 
infrequently  contain  hard  formations  in  their  pulps  at  the  latter 
period  of  involution. 

These  formations  may  be  studied  to  great  advantage  in  the 
teeth  of  mammals.  The  first  histological  investigations,  under 
the  head  of  osteo-dentine,  are  contained  in  the  "  Odontography  " 
of  R.  Owen.  In  the  teeth  of  these  animals,  also,  aside  from 
other  causative  influences,  the  frequent  occurrence  of  this  for- 
mation is  a  phenomenon  connected  with  the  senescence  of  the 
tooth.  Corresponding  to  the  centre  of  the  transversely  abraded 
surface  of  a  much  worn  lower  incisor  of  a  dog,  I  found  a  deposit 
of  transparent  secondary  dentine,  measuring  one-half  a  millime- 
tre in  depth,  and  with  its  canals  extending  in  conformity  to  those 
of  the  original  dentine.  In  several  Avorn  front  teeth  of  the 
lower  jaw  of  a  common  hedge-hog  (Erinaceus  Europ.),  I  have 
met  with  multiple  osteo-dentinal  formations  attached  to  the  wall 
of  the  root-canal.  These  were  of  an  ellipsoidal  or  cylindriform 
shape,  their  long  diameters  measuring,  in  some  cases,  one  mil- 
limetre; elongated  vascular  canals  traversed  a  few  of  the  larger 
ones;  their  central  substance  was  occupied  by  bone-corpuscles,, 
and  their  pei'ipheral  portions  were  traversed  by  an  abundance 
of  centripetal  dentinal  canals.  In  a  molar  from  a  horse,  the 
coronal  surface  of  which  was  much  worn  away  and  hollowed  out 
in  the  form  of  a  channel,  and  the  root  of  which  was  notably 
contracted  upon  either  side,  had  become  atrophied,  several  con- 
centrically laminated  new-formations,  which  were  united  to  the 
dentine,  were  found  in  the  single,  considerably  narrowed  canal. 
In  the  atrophic  roots,  near  their  junction  towards  the  neck  of 


298  NEW -FORMATIONS. 

a  molar  from  an  ox,  I  met  Avitli  very  finely  developed,  vascular- 
ized, multiple,  interstitial,  dentinal  new-formations. 

It  is  not  an  uncommon  occurrence  to  find,  in  the  ivory  from 
the  hippopotamus,  spherical  or  cylindrical  deposits  (interstitial 
new-formations),  which  are  removed  by  the  dental  artificers  as 
unserviceable;  they  are  composed  of  remarkably  fine  concen- 
tric hn^ers  of  dentine,  in  which  the  canals  of  the  different  laminne 
pursue  a  centripetal,  undulatory  course,  at  uniform  intervals  from 
each  other.  The  new-formations  are  connected  with  the  ivory 
by  means  of  a  transparent,  intermediate  layer  which  does  not 
possess  the  structure  of  dentine,  but  presents  a  structureless,  mi- 
nutely granular  basis-substance,  with  sharply  defined,  lobulated 
borders  toAvards  the  dentinal  layers.  Sometimes,  quite  distinct 
bone-corpuscles  may  be  recognized  in  this  connective  zone,  and, 
therefore,  there  can  be  no  doubt  but  that  we  have  presented  in 
it  an  osteoid  substance,  in  which  extend  numerous  vascular 
canals  with  occasional  sac-like  dilatations. 

The  stalactitic  forms,  which  occur  upon  the  wall  of  the  pulp- 
cavity  of  elephants'  tusks,  were  recognized  by  A.  Haller.  R. 
Owen  states  that  they  are,  obviously,  the  result  of  circumscribed 
inflammation  or  malformation  of  the  pulp.  In  the  root-portion 
of  tusks,  I  have  observed  very  numerous  hard  new-formations 
projecting  into  the  pulp-cavity  and  presenting  a  great  variety 
of  forms,  as  conical,  dentiform,  nodular,  lamellar,  &c.  The  very 
thin  lamellar  forms  are  composed,  principally,  of  bony  tissue, 
while  the  dentiform  or  superficially  smooth,  nodular,  thicker 
forms  consist  of  bone,  together  with  dentine  in  its  various  transi- 
tional stages,  or  principally  of  the  latter. 

It  is  not  uncommon  to  meet  with  very  imperfect  ivory  in  the 
root-portion  of  the  tusk  ;  for  instance,  osseous  tissue  may  be  im- 
bedded in  it  in  a  very  irregular  manner  and  to  a  considerable 
extent,  or  the  dentine  is  traversed  by  numerous  vascular  canals, 
at  tolerably  uniform  intervals,  or  spherical,  encapsulated,  new- 
formations  of  dentinal  substance  are  interposed;  in  consequence 
of  the  presence  of  these,  the  surface  of  a  cross-section  presents 
confluent  or  discrete  yellowish  grains,  interspersed  with  lighter 
masses;  the  grains  vary  in  size  from  that  of  the  head  of  a  pin 
to  that  of  a  pea,  and  may  even  be  larger.    These  faulty  formations 


NEW- FORMATIONS    OF    HARD    TISSUES    OF    TEETH.      299 

sometimes  extend  into  the  projecting  coronal  portion  and  arc  well 
known  to  the  ivory  turners,  since  the  ivory  containing  them  is  un- 
suitable for  very  delicate  work  on  account  of  its  diminished  hard- 
ness and  elasticity,  nor  is  it  capable  of  receiving  so  fine  a  polish. 
In  a  technical  point  of  view,  therefore,  they  are. of  importance. 

In  regard  to  the  question  whether  these  hard  formations  in 
the  pulp  have  a  'physinloglcal  or  a  pafhologiaal  signification,  it 
must,  first  of  all,  be  borne  in  mind  how  difficult  a  matter  it  is, 
as  a  rule,  to  distinguish  between  a  physiological  and  a  pathologi- 
cal phenomenon,  and  this  is  all  the  more  the  case  in  the  present 
instance  where  we  have  to  do  with  senile  chancres  in  an  oro;an, 
in  the  majority  of  cases.  Hence,  it  must  be  admitted  that  the 
answer  cannot  be  given  with  absolute  precision.  Where  do  the 
senile  phenomena  end  and  the  pathological  begin  ?  The  fact 
tliat  the  hard  new-formations  occur  in  quite  old  teeth,  present- 
ing abraded  coronal  surfaces  without  any  further  evidences  of 
disease,  and  that  they  are  of  fre(|uent  occurrence  in  the  older 
teeth  of  animals,  indicate,  to  a  certain  degree,  that  we  are  not 
to  lay  very  much  stress  upon  the  patiiological  element ;  on  the 
other  hand,  special  conditions  appear  to  be  necessary  for  their 
development,  from  the  fact  that  they  are  not  found  in  all  senile 
teeth.  They  are  to  be  considered  as  the  results  of  an  inde- 
pendent process,  which  is  based  upon  a  hypo'plastic,  local- 
ized development  of  dentine,  which  process  is  unaccompanied  by 
pain  ;  it  is  to  be  observed,  however,  that  pulps  containing  den- 
tinal new-formations  do  not  lose  their  susceptibility  to  painful 
impressions,  since  the  nerves  in  the  vicinity  of  the  new-form;)- 
tions  may  be  well  preserved  and  capable  of  conduction  ;  it  is 
quite  possible,  also,  that,  under  special  conditions,  in  teeth  on 
which  the  dentinal  covering  has  been  very  much  worn  away 
they  may  occasion  a  painful  sensation  in  consequence  of  a  me- 
chanical injury  and  that,  as  their  growth  continues,  they  may 
give  rise  to  derangements  in  the  circulation  and  even  to  in- 
flammatory processes  in  the  remaining  portions  of  the  pulp,  and 
to  consecutive  periosteal  inflammation. 

E.  Mlihlreiter*  considers  the  new-formations  of  dentine  and 

*  Deutsche  Viertelj.  f  Zahnheilkiinde,  1868. 


300  NEW -FORMATIONS. 

the  calcifications  to  be  independent  processes,  whicli  of  them- 
selves give  no  indications  of  their  occurrence  and  are  unaccom- 
panied bj  painful  sensations.  When  these  processes  are  asso- 
ciated with  other  pathological  changes,  especially  with  those  of 
an  inflammatory  nature  in  the  pulp-tissue  which  is  not  implicated 
in  the  development  of  the  new-formation,  then  they  acijuire  a 
clinical  interest  from  their  influence  upon  the  course  of  the 
morbid  process.  According  to  McQuillen,*  new-formations  of 
dentine  in  the  pulps  of  teeth,  not  affected  with  caries,  sometimes 
give  rise  to  the  most  intense  neuralgias  which,  not  infrequently, 
are  referred  to  other  teeth  and  considered  to  be  the  result  of 
sympathetic  irritation.  A  continuous,  boring,  pain  which  is 
felt  invariably  at  one  and  the  same  spot,  he  remarks,  is  a  quite 
positive  indication  of  the  presence  of  a  new-formation.  If  this 
be  the  case,  consecutive  periodontitis  ensues.  In  a  cnse  reported 
by  Tanzer,t  there  Avas  unremitting  pain  referred  to  the  last  tooth 
in  the  lower  jaw;  this  was  removed  and  the  pain  returned  in  the 
next  tooth  in  front ;  in  consequence  of  the  repeated  migration 
of  the  pain  to  the  adjacent  tooth,  one  tooth  after  another  was 
extracted,  as  far  as  the  lateral  incisor,  during  a  period  of  eight 
to  nine  years.  Each  of  the  teeth  extracted  presented  well- 
marked  examples  of  unattached  and  parietal  new-formations, 
and,  in  the  opinion  of  Tanzer,  this  man,  who  was  then  thirty- 
four  years  of  age,  probably  will  not  obtain  release  from  his 
sufl'ering  until  all  the  teeth  have  been  removed. 

The  new-formations  also  derive  importance  in  connection  with 
the  operation  of  filling,  and  Hulme|  expresses  his  ideas  upon 
this  point  in  the  following  manner:  "There  can  be  no  question, 
if  it  is  possible  to  preserve  the  pulp  of  a  tooth  and  then  stop  it, 
that  such  a  tooth  is  in  a  far  more  healthy  condition  than  Avhere 
the  interior  of  the  crown  and  the  fang  is  filled  with  gold  or  any 
foreign  material.  I  am  fully  convinced  that  many  of  the  teeth 
which  of  late  years  have  been  treated  by  destroying  the  pulp 
might,  under  another  mode  of  treatment,  have  been  preserved 
without  sacrificing  this  essential  portion  of  the  organ.     So  long 

*  Dental  Cosmos,  18G8. 

t  Deutsche  Viertelj.  f.  Ztihnh.,  1869. 

+  Dental  Keview,  18(il. 


MUSKET -BALLS    IN    THE    TEETH    OF    ELEPHANTS.       301 

as  there  is  a  layer  of  dentine  existing  over  the  pulp,  as  a  general 
rule,  it  should  never  be  removed,  even  if  the  dentine  is  softened 
nearly  to  the  surface  of  the  pulp." 

MuSKET-BALLS    IN    THE    TeETII    OF    ELEPHANTS. — Elephant- 

hunters  very  frequently  employ  firearms  and  take  aim  at  the 
eye,  ear,  nnd  mouth,  so  that  it  will  readily  be  seen  that  the 
balls,  instead  of  penetrating  through  the  skull  into  the  base  of 
the  brain,  may  enter  one  or  another  tooth  and  give  rise  to  pro- 
cesses in  the  dentine  and  the  wall  of  the  pulp-cavities,  Avhich 
acquire  a  great  pathological  interest.  Goethe,  long  ago  (1798), 
investigated  the  subject  of  diseased  ivory  from  the  elephant's 
tusk  resulting  from  the  impaction  of  iron  or  leaden  balls  ;  the 
process  appeared  to  him  to  be  a  sort  of  coagulation  (Gerinnung) ; 
he  also  mentions  the  occurrence  of  exostosis  upon  the  wall  of 
the  pulp-cavity  in  cases  where  a  ball  entered  the  posterior,  weak, 
and  hollow  portion  of  the  tooth.  Cuvier,  also,  recognized  the 
irregularity  in  the  dental  mass  around  the  balls.  R.  Owen  was 
the  first  to  call  attention  to  the  change  produced  in  the  histo- 
logical structure,  and  says  that  musket-balls  and  other  foreign 
bodies  which  become  imbedded  in  ivory  become  surrounded  by 
osteo-dentine,  in  greater  or  less  amount.  If  the  ball  penetrates 
the  root  portion  and  enters  the  pulp,  the  track  made  in  the  pas- 
sage of  the  former  becomes  filled  by  a  thick  deposit  of  cement 
from  without  and  of  osteo-dentine  from  Avithin. 

By  the  kindness  of  Prof,  von  Schroff,  I  had  the  opportunity 
of  examining  five  specimens  from  elephants'  tusks  in  which  iron 
balls  were  imbedded,  from  the  pharmacological  collection.  The 
malformed  dentine,  which  is  recognizable  by  the  naked  eye,  is 
shown  very  distinctly  in  cross-sections ;  it  has,  generally,  a 
dirty-yellow  color,  is  tolerably  well  defined  towards  the  sound 
dentine,  its  general  outline,  as  well  as  its  extent,  being  variable. 
The  tissue  is  Avanting  in  uniformity  and  presents  an  abundance 
of  interlacing  wavy  striated  markings.  This  faulty  formation, 
however,  is  not  confined  to  the  immediate  vicinity  of  the  im- 
pacted ball,  but  is  found,  also,  at  various  distances  from  it  in  the 
form  of  isolated,  concentrically-striated  patches.  The  reaction 
which  is  induced  by  the  presence  of  the  foreign  body  sometimes 
leads  to  the  formation  of  an  abscess  in  the  dentine  (comp.  p.  188). 


302  NEW -FORMATIONS. 

The  fiiult}^  formation  may  be  traced  along  the  track  made  by 
the  ball  (Fig.  86).    A  depression,  corresponding  in  size  with  that 

Fm.  SO.* 


of  the  ball,  together  -with  several  smooth  excrescences  as  large 
as  the  head  of  a  pin  (new-formations),  may  be  seen  upon  the  ex- 
terior of  the  tooth,  especially  in  cases  where  the  ball  has  pene- 
trated in  a  direction  transverse  to  the  long  axis  of  the  tooth. 

If  the  ball  traverses  the  pulp-cavity  in  a  transverse  direction, 
crushing  the  pulp  in  its  passage,  there  ensues  a  formation  of 
osteo-dentine  which,  in  the  case  illustrated,  has  a  smooth  ap- 
pearance upon  the  surface  presented  in  the  pulp-cavity  and 
consists  of  pyramidal  tubercles  and  nodules  having  a  yellowish 
color.  Thin  transverse  sections  of  the  latter  present  abundant 
globular  substance  and  entangled,  confused  masses  of  dentinal 
canals  and,  in  other  places,  multiradiated  bone-corpuscles.  In 
these  new-formations  especial  interest  is  afforded  by  a  few  oblong, 

*  Fig.  86  shows  a  section  taken  from  an  elephant's  tusk,  and  upon  the 
left  side  the  segments  of  two  iron  bullets  which  hiive  pressed  through  the 
dental  pulp  and  become  fixed,  parllj-  to  the  wall  of  the  pulp-cavity  and 
partly  to  the  contiguous  dentinal  tissue.  The  point  at  which  the  bullets 
entered  is  seen  at  [a) ;  in  a  transverse  direction  from  the  latter  may  be  traced 
the  track  traversed  bj'  them,  which  is  indicated  by  an  irregular,  zigzag 
course  of  the  strise.  The  df^ntinc.  both  in  the  vicinity  of  the  latter  and,  also, 
of  the  transversely-divided  bullets,  is  transformed  into  osteo-dentine  which 
is  quite  sharply  defined,  displays  wavy  striaj  and,  for  the  most  part,  a  dirty- 
yellowish  color.  The  hard  formation,  which  forms  a  transverse  bridge 
across  the  pulp-cavity,  presents  in  cross-section  an  irregular,  multiple,  con- 
centrically-laminated osteo-dentine.  In  the  vicinity  of  the  larger  bullet  a 
circumscribed  suppuration  occurred.     Two-thirds  natural  size. 


MUSKET-BALLS    IN    THE    TEETH    OF    ELEPHANTS.       303 

defined,  interposed  dentinal  portions,  from  one  to  several  milli- 
meti-es  in  thickness,  which  have  a  rectilinear,  angular  configura- 
tion, present  the  texture  of  the  normal  dentine  and  are  encap- 
sulated by  a  thin  layer  of  osseous  tissue.  Evidently,  they  are 
spicula  of  ivory  which  became  impacted  in  the  pulp  and  gave 
rise  to  a  proliferation  of  bone-corpuscles  by  means  of  which 
they  became  invested  by  osseous  tissue  in  the  form  of  a  sheath. 
The  osteo-dentinal  formation,  then,  succeeded  the  latter. 

In  cases  where  the  ball  penetrates 
to  the  wall    of   the    pulp-cavity  and  "^"*^'' 

the  corresponding  portion  of  the  wall 
becomes  implicated  in  the  faulty 
formation  of  the  dentine  (Fig.  87)  a 
proportionately  large  osteo-dentinal 
mass,  with  jagged  and  warty  excres- 
cences, is  found  projecting  into  the  [ 
pulp-cavity.  - 

The  pulp-wall  may,  however,  be 
protruded,  merely,  by  the  ball  and  remain  smooth  (Fig.  88). 
Osteo-dentinal  formations,  which  first  make  their  appearance 
at  some  distance  from  the  locality  of  the  ball,  may  owe  their 
origin  to  displaced  dentinal  fragments,  or  a  local  concussion, 
merely,  may  be  sufficient  to  occasion  their  development. 

As  ivory  admits  of  a  certain  amount  of  expansion,  in  conse- 
quence of  its  elasticity,  and,  moreover,  since  the  shattered  por- 
tions become  filled  with  a  reparative  tissue,  the  point  of  entrance 
of  the  ball  upon  the  exterior  of  the  tooth  may  easily  escape  ob- 
servation, and  the  ivory  turner  is  first  made  aware  of  the  pres- 
ence of  a  ball  when  he  attempts  to  saw  through  the  tusk. 

The  molars  from  elephants  are  employed  less  frequently  in 

*  Pig.  87  shows  a  segment  from  the  tusk  of  an  elephant,  containinji;  small 
fragments  of  an  iron  ball  in  the  wall  of  the  pulp-cavity.  From  the  appear- 
ance of  the  surface  of  the  section  presented  in  the  figure,  it  is  seen  that  an 
abnormal  tissue,  with  a  sharply  defined  outline  towards  the  normal  dentine, 
is  disposed  upon  the  periphery  of  the  ball,  forming  a  capsule  for  a  certain 
portion  of  the  latter,  and  represents  the  basal  jiortion  of  a  new-formation 
which,  upon  the  opposite  surface  of  the  preparation,  projects  into  the  pulj)- 
cavity  in  the  form  of  notched  and  warty,  superficially  smooth  osteo-dentine. 
Natural  size. 


304 


NEW-FORMATIONS. 


tlic  arts  and,  therefore,  there  is  rarely  an  opportunity  to  ohtain 
sections  of  them  ;  the  teeth,  moreover,  being  inclosed  within 
the  mouth,  are  less  liable  to  be  penetrated  by  balls.  A  case  in 
point,  however,  is  illustrated  in  Fig.  89,  where,  in  a  molar,  an 
osteo-dentinal  mass,  inclosing  a  flattened,  leaden  ball,  is  inter- 
posed between  the  folds  of  the  enamel,  on  the  other  side  in  the 
substance  of  the  dentine  and  is  in  relation  with  the  cement. 


Fig.  S9.t 
c  baa 


£Mi1i.K!'_^:.Ol 


New-formation  op  Osseous  Substance  in  Connection 
WITH  Abscesses  in  the  Ivory  of  the  Tusks  of  Elephants. 
— The  reparative  tissue  which  is   formed  upon  the  wall  of  an 


*  Fig.  88. — Segment  from  the  tusk  of  an  elephant,  containing-  an  iron  ball 
which  has  penetrated  as  far  as  the  pulp-cavity  and  has  formed  a  bulging 
protuberance  upon  its  wall  which  has  given  rise  to  several,  superficially 
smooth,  warty  new-formations  with  broad  bases,  partially  visible  at  {a)  in  the 
oblique  view  of  the  preparation.  In  the  immediate  vicinity  of  the  ball,  the 
cavities  of  small  abscesses  and,  also,  osteo-dentine,  are  pt^rceptible.  Two- 
thirds  natural  size. 

f  Fig.  89  shows  a  portion  of  a  transverse  section  of  the  molar  from  an 
Elephas  Indicus  from  Ceylon,  containing  the  flattened  segment  of  a  leaden 
ball.  (For  the  use  of  this  specimen  the  author  is  indebted  to  Prof.  D.  L. 
Schmarda.)  If  the  three  dental  substances  be  traced  out,  it  will  be  seen  that 
the  enamel  [a,  a),  at  a  certain  distance  from  the  fragment  of  the  ball,  and 
also  the  dentine  (b,  h),  have  been  displaced  by  a  substance  (c,  c),  which  forms 
an  investment  of  varying  thickness  around  the  fragment  of  the  ball  and, 
when  traced  farther,  is  found  to  enter  into  immediate  connection  with  the 
cement.  Hence  the  new-formation  was  developed  by  a  proliferation  into 
the  enamel  and  dentine.     Natural  size. 


NEW-FORMATION    OF    BONE    WITH    ABSCESS    IN    IVORY.    305 

abscess  in  ivory,  is  osseous  substance,  as  has  been  shown  before 
(compare  Inflammations,  p.  188).  The  very  marked  prolifera- 
tion of  the  osseous  tissue  encroaches  upon  and  induces  a  resorp- 
tion of  the  ivory  at  the  corresponding  parts ;  the  contour  of  the 
interstitial  new-formation,  therefore,  is  not  clearly  defined. 
The  zone  of  proliferating  osseous  tissue  varies  in  its  extent  be- 
tween several  square  millimetres  and,  perhaps,  a  square  cen- 
timetre, and  presents  a  marbled  appearance.   (Fig.   90.)     The 

Fig.  90.* 


brighter,  more  transparent  portions  correspond  to  the  osseous 
substance,  the  less  transparent,  insulated  portions,  hemmed  in 


*  Fig.  90  shows  an  osseous  new-formation  from  the  wall  of  the  cavity  of 
an  abscess  in  the  tusk  of  an  elephant.  (The  specimen  was  taken  from  the 
portion  of  the  segment  indicated  by  a,  in  Fig.  75.)  From  the  internal  sur- 
face (a)  of  the  cavity  of  the  abscess  as  far  as  (c),  where  the  normal  dentine 
commences,  the  dentine  is  displaced  by  an  abundantly  vascularized  osseous 
layer.  The  bloodvessels  are  transversely  divided,  for  the  most  part,  and  are 
surrounded  by  a  luminous  ring.  The  opaque,  dotted  portions  (6)  corres- 
pond with  the  localities  where  granular  cloudiness  is  visible,  and,  here  and 
there,  the  remains  of  the  ivory  may  still  be  recognized.  The  brighter  spots 
contain,  for  the  most  part,  bone-corpuscles  which  appear  in  the  figure  in  the 
form  of  puncta ;  in  many  places,  e.  c/.,  near  the  middle  portion  (indicated 
by  transverse  lines),  the  bone-corpuscles  are  wanting,  and  in  place  of 
them  is  seen  merely  a  diffused,  granular  mass.  At  the  zone  of  transition 
into  normal  dentine  (c),  quite  bright  spots  are  perceptible  upon  the  right  side, 
which  are  suggestive  of  clustered  globular  masses  ;  upon  the  left  are  the  open- 
ings of  transversely  and  obliquely  divided  bloodvessels,  which  are  surrounded 
by  a  luminous  ring  and  are  imbedded  within  the  dentinal  substance.  Mag- 
nified five  diameters. 

20 


306  NEW- FORMATIONS. 

by  the  latter,  correspond  to  the  dentine  which  has  undergone 
resorption. 

The  osseous  substance  in  the  vicinity  of  the  cavity  of  the 
abscess  presents  all  the  characteristics  of  a  young  bony  tissue  ; 
the  osteoblasts  inclose  a  nucleus  together  Avith  prominent 
nucleoli,  and  present  a  variety  of  forms  resulting  from  division ; 
their  canaliculi  are  met  with,  chiefly,  in  the  form  of  short,  den- 
tated  prolongations  from  the  body  of  the  cell ;  several  osteo- 
blasts, also,  are  inclosed  within  a  common  cavity  with  an  indented 
outline.  In  the  deeper  layers  of  the  new-formation  which  sur- 
rounds the  cavity  of  the  abscess,  young,  osseous  substance 
occurs,  particularly  in  the  neighborhood  of  the  vascular  canals, 
which  latter  are  invested,  as  with  a  sheath,  by  a  light  substance 
composed,  in  part,  of  minute  globules  and,  in  part,  of  con- 
centric layers  with  radiated  markings.  It  is  hardly  necessary 
to  add  that  the  latter  corresponds  to  an  osteoid  formation. 
Numerous  vascular  canals  are  prolonged  into  the  ivory,  ad- 
vanced guards,  as  it  were,  Avhich  serve  as  the  medium  through 
which  the  resorption  of  the  ivory  and  the  formation  of  bony  sub- 
stance are  effected;  I  have  been  unable  to  ascertain  their  origin, 
as  only  segments  of  tusks  were  at  my  disposal. 

I  endeavored  to  identify,  in  the  dried  mass  which  lines  the 
cavity  of  an  abscess,  a  vascularized  connective  tissue  from  which 
the  bloodvessels,  that  are  prolonged  towards  the  ivory,  may  pos- 
sibly have  originated,  but  was  unable  to  come  to  any  satisfactory 
conclusion,  in  consequence  of  the  marked  degeneration  of  the 
mass. 

The  resorption  of  the  ivory  is  presented  in  various  stages,  as 
has  been  referred  to  before  (compare  Inflammations,  p.  189). 
The  first  indications  are  afforded  by  the  appearance  of  numerous 
minute  cavities,  with  indented  margins,  which  resemble  inter- 
globular spaces  and  gradually  render  the  dentinal  canals  less 
recognizable,  so  that,  finally,  there  remains  only  a  substance  re- 
sembling minute  globular  masses,  the  limits  of  which  are  gradu- 
ally contracted  b}^  the  encroachment  of  the  osseous  substance. 
We  find,  then,  that  in  the  vicinity  of  these  chronic  abscesses, 
also,  a  more  vigorous  reparative  tissue  is  developed  in  the  place 
of  the  less  vigorous ;    in  other  words,  an  interstitial  growth  of 


FRACTURED    TEETH.  307 

osseous  substance  ensues  in   the  vicinity  of  the  cavity  of  the 
abscess. 

Fractured  Teeth. — Since  fractures  of  the  teeth,  produced 
by  blows,  thrusts,  falls  and  awkward  attempts  at  extraction, 
cannot  be  regarded  as  uncommon  occurrences,  it  might  be  ex- 
pected that  among  a  very  large  number  of  teeth  an  instance  of 
a  reunited  fracture  would  be  met  with  now  and  then.  But  we 
may  examine  thousands  of  teeth  which  have  been  extracted 
during  life  or  removed  after  death  without  meeting  with  a  single 
case  of  a  reunited  fracture.  Formerly,  therefore,  the  occurrence 
of  the  latter  was  doubted,  but  the  accurate  observations  of 
modern  times  have  settled  the  matter  beyond  cavil.  Hohl 
recently*  collected  all  the  known  cases  of  reunited  fractures, 
fourteen  in  number,  including  two  cases  observed  by  himself. 
Three  cases  occurred  in  the  teeth  of  the  hippopotamus,  two  in 
those  of  the  horse,  one  in  the  tooth  of  an  antelope,  seven  in  human 
incisors,  and  one  in  an  upper  bicuspid.  If  we  add  the  case  of 
Rogers,  mentioned  by  Toraes,t  in  which  an  upper  molar  was  broken 
off"  transversely  at  the  neck,  there  will  be  fifteen  cases  in  all. 

When  we  consider  the  great  frequency  of  conflicts  among  ani- 
mals, it  will  readily  be  understood  that  the  canines  of  the  larger 
mammals,  which  are  employed  as  Aveapons  for  giving  blows,  pre- 
sent a  large,  unprotected  surface  and  are  exposed  to  manifold 
external  influences,  are  quite  liable  to  meet  with  severe  mechani- 
cal injuries,  and  it  is  probable  that  more  careful  observations 
will  show  that  with  these  animals,  fractures  of  the  teeth  are  not 
such  rare  occurrences  as  has  been  supposed. 

Reunited,  comminuted  fractures  aff'ord  evidence  of  the  remark- 
able increase  in  the  vital  activity  which  may  be  manifested  in  a 
tooth.  J.  Tomesj  mentions  an  instance  of  a  severely  com- 
minuted fracture  of  the  tusk  of  a  hippopotamus,  within  the 
socket  and  with  considerable  displacement  and  quite  wide  sepa- 
ration of  the  fractured  portions.  In  this  case,  union  took  place, 
and  was  eff'ected  by  the  development  of  cement.  In  a  case  of 
reunited  fracture  of  the  lower  canine  of  a  hippopotamus,  de- 


*  Deutsche  Viertelj.f.  Zahnheilk.,  1870. 

f  System  of  Dental  Surgery.  %  System  of  Dental  Surgery. 


308  NEAV -FORMATIONS. 

scribed  by  Owen,*  the  reparative  tissue  was  composed  of  osteo- 
dentine,  and  this  may,  possibly,  be  the  case  in  all  instances  where 
the  pulp  participates  in  the  reparative  process. 

Two  cases  of  united  fracture,  one  of  a  human  upper  bicuspid 
and  the  other  of  a  lower  incisor  of  an  antelope,  Avhich  were  re- 
ported by  myself,t  and  are  illustrated  in  the  Atlas,  Figs.  73-78, 
inclusive,  afford  a  very  clear  idea  of  the  character  of  the  repara- 
tive tissue. 

In  both  cases,  Avhich  are  distinct  from  each  other,  there  is 
presented  a  completed  reparative  process  which  originated  in  the 
root-pulp  in  the  first  case,  where  the  fracture  was  through  the 
root  of  the  tooth,  and  in  tlie  coronal  pulp  in  the  second  case, 
where  the  fracture  occurred  in  the  crown.  In  both,  a  firm  re- 
parative tissue  was  developed,  consisting  essentially  of  three  dif- 
ferent substances,  namely,  dentine,  globular  masses,  and  bone. 
In  the  first  case,  it  formed  a  firm  cement  by  means  of  which  the 
union  of  the  two  fractured  ends  was  effected,  and  in  the  other,  a 
protective  covering  for  the  body  of  the  pulp.  In  the  latter  case, 
then,  it  was  more  like  a  cicatrization  of  the  pulp. 

In  the  first  case,  the  regeneration  of  hard  tissues  was  effected, 
principally,  from  the  root-pulp,  and  only  to  a  limited  degree  from 
the  periosteum  of  the  root.  The  systems  of  dentinal  canals, 
which  are  interposed  in  the  substance  of  the  callus,  must  have 
originated  from  a  proliferation  of  the  dentinal  cells  between  the 
fractured  ends.  The  new-formed  osseous  substance,  which  is 
disposed  upon  the  fractured  portions  of  the  dentine,  is,  likewise, 
a  product  of  the  root-pulp,  the  production  of  osseous  substance 
from  the  latter  being  possible,  as  we  know;  th'e  cement-layers 
corresponding  with  the  fracture,  are  not  thickened  and,  there- 
fore, the  periosteum  of  the  root,  the  medium  through  which  the 
nourishment  and  growth  of  the  cement  is  effected,  has  furnished 
merely  a  cementing  substance  upon  the  periphery  of  the  frac- 
ture. The  proliferation  of  the  osseous  substance  between  the 
fractured  surfaces  of  the  dentine  is  prolonged  for  some  distance 
into  the  substance  of  the  latter,  so  that  the  fractured  portions 
are  intimately  united. 


*  Odontography.  f  Deutsche  Viertelj.  f.  Zahnheilk.,  1867. 


TRANSVERSELY    OR    OBLIQUELY    FRACTURED    ROOTS.       309 

In  the  second  case,  in  Avliich  the  outer  segment  of  the  crown 
^vas  broken  ofF,  an  osteo-dentinal  mass  was  developed  from  the 
body  of  the  pulp  outwards,  and  presented  the  following  appear- 
ances. The  proliferated,  abundantly  vascularized,  dentinal  sub- 
stance was  covered  over  with  bone  which,  likewise,  was  traversed 
by  numerous  vascular  canals,  an  arrangement  similar  to  that 
presented  in  the  first  case.  It  is  very  common,  indeed,  to  ob- 
serve that  a  new-formation  of  dentine  is  accompanied  by  that 
of  bloodvessels,  which  latter,  however,  gradually  become  oblit- 
erated and  undergo  calcification.  In  consequence  of  a  defect 
in  the  wall  of  the  pulp-cavity,  it  was  possible  for  the  proliferating 
hard  tissue  to  project  beyond  the  edge  of  the  fracture,  and  the 
surface  beyond  the  new  dentine  became  the  seat  of  an  ossifica- 
tion process. 

A  concurrence  of  favorable  circumstnnces  is  requisite  in  order 
to  insure  the  complete  union  of  a  transverse  or  oblique  fracture  of 
the  root  of  a  tooth.  First  of  all,  it  is  necessary  that  the  frac- 
ture should  be  simple,  as  nearly  as  possible,  and  without  any 
aggravating  complication.  If  the  pulp  is  subjected  to  great 
traction,  is  crushed  or  lacerated,  its  suppuration  or  gangrene 
will  be  all  the  more  likely  to  occur  and  to  interfere  with  the 
reparative  process  and  occasion  the  death  of  both  the  fractured 
portions.  If,  on  the  other  hand,  a  large  portion  of  the  periosteum 
of  the  root  is  injured,  a  consecutive  inflammation  will  furnish  an 
insurmountable  obstacle  to  the  process  of  repair.  The  connec- 
tion of  the  tooth  with  its  socket  must  not  be  so  far  broken  that 
the  fixation  of  the  former  in  the  latter  is  impossible.  A  repair 
also  requires  a  healthy,  vigorous  condition  of  the  individual,  and 
a  proper  care  of  the  fractured  parts  after  they  have  been  ap- 
proximated. Absence  of  these  favorable  conditions  and  neglect 
of  proper  precautions  are  to  be  regarded  as  the  probable  causes 
of  the  comparative  infrequency  of  reunited  fractures  of  the  roots 
of  teeth,  which  the  dentist  is  called  upon  to  extract  in  conse- 
quence of  the  intense  pain  Avhich  the  patient  experiences  from 
them. 

In  a  case  observed  by  Saunders,*  the  fracture  extended  ob- 

*  J.  Tomes'  Lectures  on  Dental  Physiology  and  Surgery. 


310  NEW- FORMATIONS, 

liquely  throuo;li  the  middle  of  the  root  of  a  human  incisor;  per- 
fect union  took  place  with  slight  displacement.  In  a  case  which 
occurred  in  the  practice  of  J.  Tomes,*  a  front  tooth  of  a  patient 
under  twenty  years  of  age,  was  fractured  transversely  hy  a  severe 
fall.  After  the  lapse  of  some  time  the  patient  determined  to 
submit  to  no  further  inconvenience,  and  the  tooth  was  extracted. 
The  tooth  had  been  broken  transversely,  some  distance  within 
the  socket,  and  the  fractured  surface  had  been  coated  over  sub- 
sequently with  cementum.  Had  the  tooth,  continues  Tomes, 
been  kept  for  a  time  by  any  mechanical  means  in  a  state  of  rest, 
it  is  probable  that  a  union  of  the  fractured  surfaces  would  have 
been  effected. f  A  case  of  reunited  fracture  of  an  incisor  is  con- 
tained in  the  Breslau  Anatomical  Museum.];  The  root  of  a 
student's  incisor  was  broken  across  with  a  fencing  foil,  in  the 
gymnasium.  The  fragment  was  found  to  be  still  attached  to 
the  gum,  and  Avas  pressed  back  into  the  socket  by  the  surgeon  in 
attendance.  It  regained  its  original  firmness,  but  there  ensued 
such  intense  pain  that  it  afterwards  became  necessary  to  remove 
the  tooth,  which  presented  a  slight  lateral  displacement  of  its 
consolidated  fragments;  the  nerves  were  found  to  be  bent  from 
their  course  at  the  corresponding  part,  and  this  condition,  to- 
gether with  the  compression  to  which  they  w^ere  subjected  by 
the  encircling  callus,  gave  rise  to  the  odontalgia.  In  a  case  of 
a  perfectly  united  fracture  of  an  upper  bicuspid,  in  Heider's 
collection,  there  is  scarcely  any  displacement  of  the  fractured 
surfaces  which  are  separated  by  an  interval  of  only  0.7  of  a 
millimetre,  the  latter  being  occupied  by  newly-formed  compact 
tissue,  which  unites  the  two  surfaces.  Hoh]§  refers  to  the  fol- 
lowing case :  "  A  boy,  thirteen  years  of  age,  fell  from  the  roof  of  a 
house  and  fractured  the  right  upper  central  incisor  in  such  a  way 
that  its  crown  could  be  moved  backwards  and  forwards,  and  it 


*  System  of  Dental  Surgery. 

f  The  author  has  neglected  to  insert  an  important  portion  of  Tomes'  de- 
scription of  this  case,  in  which  "  a  front  tooth  was  broken  across  and  a  molar 
tooth  loosened  by  the  fall.  The  latter  tooth  was  allowed  to  remain,  on  the 
chance  of  its  regaining  its  original  iirmness  of  implantation.  After  the 
lapse,  &c." — Trs. 

1  Hyrtl,  Topograph.  Anatomic,  Bd.  I.  §  Op.  cit. 


LONGITUDINAL    FRACTURE    OF    GROWN    AND    ROOT.      311 

was  feared  that  the  tooth  would  drop  out.  However,  it  became 
firmer  from  day  to  daj^  and  in  a  few  weeks  it  regained  its  nor- 
mal firmness.  I  saw  the  boy  about  a  year  after  the  occurrence 
of  the  fracture.  The  tooth  differed  from  the  rest  of  the  teeth 
present  in  the  mouth,  neither  in  respect  to  color  or  degree  of 
firmness.  The  crown  presented  two  small  defects  in  the  enamel. 
Upon  the  labial  surface  of  the  alveolus  of  the  tooth  in  question, 
a  slight  bulging  could  be  felt  quite  distinctly,  about  fifteen  mil- 
limetres from  the  edge,  and  this,  evidently,  was  the  locality  of  the 
fracture." 

Longitudinal  fractures  of  the  croivn  and  root,  also,  may  become 
perfectly  united,  and  even  the  enamel  in  the  fractured  portion 
may  become  united  by  cement  tissue.  Hohl  reported  the  fol- 
lowing case:  "Prof.  V  ,  as  he  was  about  entering  a  railway  car, 
on  his  way  to  take  charge  of  a  hospital  in  Bohemia,  in  the  year 
1866,  fell,  striking  his  mouth  upon  the  sharp  edge  of  an  iron  step 
in  such  a  way  that  the  upper  large  incisor  on  the  right  side  was 
broken  lengthwise.  The  fracture  separated  the  tooth  in  the 
middle  of  the  crown  so  completely,  that  the  two  fragments  di- 
verged from  each  other  and  could  be  moved  back  and  forth. 
After  the  lapse  of  fourteen  days,  during  which  time  intense  pain 
entirely  prevented  the  use  of  the  fractured  tooth,  a  more  com- 
fortable condition  ensued,  and  in  a  few  weeks  more  the  tooth 
completely  resumed  its  normal  functions.  At  the  present  time, 
the  two  halves  of  the  tooth  are  firmly  adherent  to  one  another, 
and  the  direction  of  the  fracture  is  indicated  merely  by  a  fine 
line,  with  a  slightly  brownish  tinge.  As  the  line  is  perpendicu- 
lar to  the  transverse  axis  of  the  tooth,  it  is  to  be  presumed  that 
the  fracture  also  involved  the  root."  To  this  category,  also, 
probably  belong  the  united  fractures  of  two  molars  of  a  horse, 
contained  in  the  Museum  of  Berne,  with  regard  to  which  Valen- 
tin* states  that  the  fissures  of  both  the  enamel  and  true  dentine, 
which  were  produced  by  the  original  injury,  are  closed  by  true 
bony  tissue. 

Transverse  and  oblique  fractures  of  the  crown,  in  which  the 
pulp  is  wholly  or  partially  exposed,  lead  in  rare  cases  to  a  re- 

*  Wagner's  Handworterbuch  der  Physiologie,  Bd.  I. 


312  NEW- FORMATIONS. 

markable  cicatrizinir  process  on  the  part  of  the  pulp.  J.  Tomes* 
reports  a  case  in  point  from  Arnold  Rogers.  A  patient  applied 
to  have  the  roots  of  a  first  molar  removed,  the  crown  of  which 
had  been  broken  off,  previously,  when  attempts  were  made  to 
extract  it  for  the  relief  of  intense  pain  consequent  upon  caries. 
After  the  lapse  of  several  months,  the  remains  of  the  broken 
tooth  occasioned  annoyance  and,  therefore,  were  removed.  It 
was  found  that  secondary  dentine  had  been  formed,  which  not 
only  projected  from  the  cavity  but,  also,  overlapped  and  con- 
cealed the  sharp  edges  produced  by  the  fracture.  We  have  met 
with  a  case  quite  similar  to  the  latter,  in  an  oblique  fracture  of 
the  crown  of  a  tooth  of  an  antelope. 

The  diagnosis  of  a  fracture  of  the  root,  now  and  then,  may 
be  attended  with  difficulty,  and  Hohl  refers  particularly  to  the 
danger  of  confounding  such  a  case  with  a  luxation.  Extracted 
teeth  which  present  irregulai-ities  of  formation  in  the  form  of 
bent  or  twisted  crowns  or  bent  roots  (comp.  p.  134),  may  be 
misinterpreted  as  cases  of  fracture,  if  sufficient  care  be  not  ex- 
ercised in  ascertaining  the  true  condition. 

Cement — Osteomata — Exostoses. — Although  these  are,  es- 
sentially, localized  hypertrophies,  it  is  justifiable,  however,  from 
a  clinical  point  of  view,  to  consider  them  separately,  since  the}'' 
are,  sometimes,  the  cause  of  very  severe  pain  and  even  of  neu- 
roses in  remote  parts,  which  is  not  the  case,  usually,  with  ordi- 
nary hypertrophies. 

Osteomata  ai'e  distinguished  as  single  and  multiple,  discrete 
and  confluent.  The  solitary  osteomata  generally  have  the  form 
of  tuberous  excrescences  (Knotchen),  with  broad  basal  portions, 
and,  usually,  occur  in  the  vicinity  of  the  apex  of  the  root;  gen- 
erally they  have  a  diameter  of  a  few  millimetres,  and  a  rounded 
convex  outer  surface  which,  in  most  cases,  is  marked  with  mi- 
nute elevations  and  depressions.  They  rarely  attain  such  di- 
mensions as  were  presented  in  the  case  of  a  canine  tooth  illus- 
trated by  J.  F.  Meckel, t  where  the  osteoma  originated  at  the 
neck  and  invested  the  entire  root;  the  thickest  portion  was 
upon  the  facial  side ;    the  surface  was    smooth  in  some  places, 

*  System  of  Dental  Surger3\  |  TabultB  anat.  pathol.,  Fasc.  III. 


CEMENT — OSTEOMATA — EXOSTOSES.  313 

■while  in  others,  it  was  marked  with  seveial  pits.  According  to 
the  illustration,  the  thickest  portion  of  the  tumor  measured  2.1 
centimetres.  The  knotty,  discrete  osteomata  occur  in  groups 
of  two  or  three,  at  slight  intervals  from  each  other,  or  are 
massed  together  so  as  to  present  a  warty  appearance  (Atlas, 
Fig.  108).  Numbers  of  delicate  spinous  and  lamellar  excres- 
cences, which  are  to  be  distinguished  from  appearances  result- 
ing from  resorption  and,  sometimes,  spread  over  the  entire 
periphery  of  the  root,  impart  a  rough  character  to  the  outer 
surface  of  the  cement.  The  bicuspids  and  molars,  more  fre- 
quently than  other  teeth,  present  this  condition,  and  sometimes, 
merely  one  surface  of  the  root  is  the  seat  of  a  large  osteoma, 
while  the  remaining  roots  or  surfaces  of  a  root  are  entirely 
free. 

Histologically.,  they  consist  of  circumscribed  superpositions  of 
new  layers  of  osseous  substance,  which  are  developed,  one  over 
another,  in  the  form  of  a  dome,  with  the  base  resting  upon  the 
original  cement  (Atlas,  Fig.  107) ;  they  form  irregular  undula- 
tions beyond  the  level  of  the  cement,  and  compose  the  sole  ele- 
ments of  the  pyramidal  excrescence,  the  outer  surface  of  which, 
generally,  is  covered  with  tuberculated  prominences.  Their  sub- 
stance is  rendered  cloudy,  alwaj's,  by  ttie  presence  of  less  trans- 
parent and  even  opaque  layers,  and  to  this  condition  is  to  be 
referred  the  fact  that,  when  viewed  with  the  naked  eye,  the  os- 
teomata appear  brighter  and  whiter  in  comparison  with  the  nor- 
mal cement. 

In  respect  of  size,  form,  disposition,  and  number,  the  bone- 
corpuscles  present  a  great  variety.  The  remarkably  uniform 
laminte,  which  are  readily  brought  into  view  after  the  extraction 
of  the  calcareous  salts  by  means  of  dilute  hydrochloric  acid,  are 
disposed  in  a  concentric  manner,  present  radiated  markings  and 
are  most  conspicuous  where  the  basis-substance  occurs  in  greatest 
abundance  and  the  bone-corpuscles,  consequently,  are  separated 
by  the  widest  intervals.  The  radiating,  striated  markings  can- 
not possibly  be  occasioned  by  the  bone-canaliculi ;  indeed,  even 
with  the  use  of  very  high  magnifying  powers,  there  are  places 
which  do  not  contain  a  single  canaliculus;  but  reasoning  from 
the  analogy  between  them  and  the  appearances  presented  by  the 


314  XEAV- FORMATIONS. 

concentric  radiations  of  concretions,  e.  g.,  of  carbonate  of  lirne 
in  the  urine  of  herbivorous  animals,  especially  of  the  horse,  and 
in  renal  cysts,  or  of  uric  acid  in  vesical  calculi,  it  seems  to  me 
in  the  highest  degree  probable  that  they  are  produced  rather  by 
a  radial  disposition  of  needle  crystals  of  calcareous  salts  in  the 
layers  of  the  basis-substance.  In  another  view,  this  arrangement 
also  occasions  a  minutely-granular  marking,  which,  sometimes, 
assumes  a  yellowish  or  yellow-brownish  color  from  the  deposit 
of  pigment. 

Young,  interstitial  bone-corpuscles,  clustered  together  and 
surrounded  by  a  capsule,  are  met  with,  sometimes,  in  the  pe- 
ripheral zones,  and  are  crowded,  as  it  were,  into  the  older  layers. 
The  latter  undergo  a  necrobiosis  in  places,  and  the  still  trans- 
parent bone-corpuscles  lie  in  the  dirty  yellow,  yellow-brownish, 
brownish-black  basis-substance  which  has  undergone  a  granular 
metamorphosis.  Those  bone-canaliculi,  which  are  elongated,  ex- 
tend in  parallel  rows  and,  in  this  respect,  are  suggestive  of  den- 
tine, become  the  seat  of  accumulations  of  an  opaque,  granular 
mass,  iu  consequence  of  which  they  frequently  present  a  more 
voluminous  appearance.  The  necrobiosis  commonly  occurs  in 
circumscribed  spots,  and  is  associated  with  the  frequently- oblit- 
erated vascular  canals  which  for  the  most  part  are  of  small 
calibre  and  quite  few  in  number  as  a  general  rule.  I  have  not 
met  with  any  case  in  which  ramifications  of  the  latter  were  to 
be  seen. 

If  a  decalcified  section  be  boiled  in  very  dilute  hydrochloric 
acid  until  it  acquires  a  pultaceous  consistence,  or  nearly  liquefies, 
the  sharply-defined  osteoblasts  with  their  short  processes  will  be 
brought  into  vieAv,  either  isolated,  in  consequence  of  the  lique- 
faction of  the  basis-substance,  or  still  imbedded  in  the  latter 
which  becomes  remarkably  clear.  The  more  delicate  ramifica- 
tions of  the  bone-canaliculi  succumb  immediately  to  the  liquefying 
action  of  the  acid,  while  the  elongated,  thicker  ones,  which  extend 
towards  the  periphery,  resist  the  action  much  longer  and  may 
be  traced  to  a  considerable  distance ;  in  the  vicinity  of  the  pe- 
ripheral portions  of  the  new-formation,  isolated  osteoblasts  with 
thick,  frequently  varicous  processes  are  met  with,  which,  prob- 


CEMENT — OSTEOMATA  — EXOSTOSES.  315 

ably,  belong  to  the  derivative  forms.  The  younger  the  osteo- 
blasts, the  more  readily  may  they  be  isolated. 

The  cement  osteomata  are  developed  slowly,  give  rise,  fre- 
quently, to  intense,  piercing,  gnawing,  lancinating  pains,  and 
may  even  occasion  prosopalgia  (comp.  Neuroses).  A  case  came 
under  the  observation  of  J.  L.  Levison,*  where  death  ensued 
from  an  exostosis  of  the  root,  which  gave  rise  to  an  affection  of 
the  membranes  of  the  brain.  The  marked  painfulness  is  due  to 
the  increased  tension  of  the  nerves  of  the  periosteum  of  the  root, 
and  to  the  secondary  affection  of  the  branches  of  the  nerves  of 
the  pulp.  The  location  of  the  exostoses,  at  the  apex  of  the  root, 
renders  the  latter  all  the  more  liable  to  occur.  Whether  or  not 
the  existence  of  gout  favors  their  development  is  still  unde- 
termined. 

Quite  extensive  bony  excrescences  upon  the  cement  also  occur 
as  anomalies  of  development,  and  the  two  following  are  to  be 
regarded  as  cases  in  point.  Forget,  in  his  anomalies  of  the 
teeth,  cites  a  case,  communicated  to  himself  by  Maisonneuve, 
where  a  carious  lower  molar  presented  a  tumor  as  large  as  a 
pigeon's  egg,  which  was  attached  to  the  root,  rather  upon  the 
lateral  surface,  by  means  of  a  pedicle,  and  was  composed  entirely 
of  osseous  substance.  A  longitudinal  section  displayed  a  line  of 
demarcation  between  the  tumor  and  the  root.  The  connection 
of  the  two  was  so  intimate  that  in  the  preliminary  extraction  of 
the  tooth  for  the  purpose  of  facilitating  the  examination  and 
separation  of  the  encysted  mass,  the  latter,  also,  was  removed. 
Letenneurf  met  with  a  tumor  in  the  lower  jaw  of  a  woman, 
thirty-four  years  of  age.  When  extirpated,  it  presented  an 
irregular  form  and  was  three  and  a  half  centimetres  in  length 
and  two  and  a  half  in  breadth  ;  the  adjacent  bicuspid  was  com- 
pletely developed,  of  a  white  color,  and  attached  by  its  apex  to 
one  side  of  the  tumor.  The  latter  presented  a  gray  color,  the 
hardness  of  ivory,  and  resulted  from  an  hyperplasia  of  the 
cement,  which  process  commenced  during  the  second  dentition 
(at  the  age  of  seven  or  eight  years)  and  twenty-six  years  later 

*  Quarterly  Journal  of  Dental  Science,  1857. 
f  Gazette  des  Hopitaux,  1868, 


31G  NEW- FORMATIONS. 

was  succeeded  by  a  necrosis  which  was  ushered  in  by  the  appear- 
ance of  an  abscess.  The  tumor  attached  to  the  radical  portion 
of  a  wisdom  tooth,  illustrated  in  the  Atlas,  Figs.  28  and  29,  is 
an  osteo-odontoma  Avhich  was  developed  in  connection  with  the 
formation  of  the  dentine  of  the  roots,  and  differs  essentially  in 
structure  from  the  two  cases  Avhich  have  been  cited. 

The  cement,  even  when  it  is  hypertrophic,  as  has  already 
been  observed,  in  consequence  of  resorption  following  inflamma- 
tion or  hypertrophy  of  the  periosteum  of  the  root  acquires  a 
rough  outer  surface  which  is  not  to  be  confounded  with  the 
roughness  presented  by  osteophyte-like  outgrowths  on  the  ce- 
ment. In  consequence  of  the  resorption  accompanying  inflam- 
mation of  the  root-membrane,  a  thorn-like  process  sometimes  is 
formed  at  the  radical  extremity,  which  is  merely  the  remnant 
of  the  apex  and  upon  which  the  indications  of  resorption  may 
be  identified  ;  such  a  process,  if  not  carefully  examined,  may  be 
mistaken  for  a  thorn-like  exostosis. 

RooT-MEMBKANE. — Ncw-fonnations  of  this  membrane  occur 
either  primarily  or  secondarily  in  the  form  of  localized  thicken- 
ing's or  tumors  which  are  to  be  classed  with  the  fibrous,  sarcom- 
atous,  or  cancerous.  E.  Magitot  collected  eighteen  cases  in  a 
monograph  upon  this  subject.*  In  his  opinion,  the  tumors,  under 
certain  conditions,  originate  in  the  intervals  between  the  roots  or 
involve  the  greater  portion  or  the  whole  of  the  root-membrane ; 
they  vary  in  size  between  that  of  a  pea  and  a  hazelnut ;  they 
are  very  variable  in  form,  occur  only  upon  the  bicuspids  and 
molars,  at  any  time  of  life,  and  generally  are  single,  but  in  quite 
rare  cases,  several  tumors,  independent  of  each  other,  are  met 
with.  From  examinations  conducted  by  Robin,  Magitot  con- 
cluded that  a  substance,  which  is  a  modification,  more  or  less,  of 
the  root-membrane,  always  forms  the  stroma  and  the  funda- 
mental tissue  of  the  alteration,  and  he  divides  the  tumors  of  the 
dental  periosteum  into  five  groups,  as  follows:  1,  fibrous,  in 
which  there  is  an  hypertrophy  of  the  normal  elements  with  a 
predominance  of  fibrous  tissue ;  2,  fibroplastic,  with  a  predomi- 
nance of  nuclei,  or  spindle-shaped  cells ;  3,  epithelial  (epithelioma, 

*  Memoire  sur  les  Tumeurs  du  Perioste  Dentaire,  1860. 


ROOT-MEMBRANE.  317 

cancer  of  authors),  with  flattened,  sometimes  multi-nucleated  cells 
in  the  condition  of  fatty  defeneration  ;  4,  tumors  with  myelo- 
plaxes,  the  principal  constituents  of  which  are  multi-nucleated 
cells;  5,  tumors  with  cytoblastions,  in  which  free  nuclei  with 
granular  contents  and  Avith  no  nucleolus  are  the  prevailino- 
elements. 

I  have,  likewise,  observed  the  first  three  of  the  above-quoted 
developmental  forms;  the  fourth,  where  the  myeloplaxes  (multi- 
nucleated, gigantic  cells)  are  the  principal  elements,  apparently 
are  of  quite  rare  occurrence,  since  Magitot  cites  only  one  obser- 
vation of  the  kind.  The  fifth  group  I  class  with  the  sarcomata 
and  the  nuclei  are  not  free,  but  are  surrounded  by  a  layer  of 
protoplasm.  Between  the  fibrous,  more  consistent  tumors  which 
consist,  principally,  of  spindle-shaped  cells  with  a  well-marked, 
fibrillated  intercellular  substance,  and  the  sarcomatous  which 
contain,  principally,  small  cells,  with  scanty,  ill-defined  fibrillated 
intermediate  substance,  there  are  mixed  forms  in  Avhich  the 
tumor  presents  a  predominance  of  the  fibrous  element  in  some 
places,  and  in  others,  of  the  sarcomatous.  A  purulent  infiltra- 
tion sometimes  takes  place  in  the  peripheral  portions  of  the 
new-formation,  when  it  becomes  implicated  in  an  inflammatory 
affection. 

Cancerous  tumors  of  the  root-membrane  I  have  observed  only 
in  association  with  cancerous  infiltrations  of  the  surrounding 
parts,  in  which  cases  the  root-membrane  was  thickened,  more 
or  less,  or  marked  with  pale,  smooth,  conical  protuberances  (with 
epithelial  cancer).  Cross-sections  present  a  wide-meshed  net- 
work of  thin  connective-tissue  bundles,  the  meshes  of  which  are 
filled  with  agglomerations  of  flattened,  polymorphous  cells,  con- 
taining one  or  two  large  nuclei  and  a  generally  minutely  gran- 
ular, cloudy  protoplasm.  Numerous  layers  of  these  cells  are 
found  upon  the  surface  of  the  cones.  In  connection  with  cancer 
of  the  bone  of  the  upper  jaw,  I  have  also  observed  cancerous 
infiltration  of  the  periosteal  membranes  of  the  front  teeth. 

Magitot  divides  the  symptoms  induced  by  tumors  of  the  root- 
membrane  into  those  which  are  local,  confined  to  the  aff'ccted 
part,  those  which  have  their  seat  in  the  adjacent  part,  those 
arising  from  aff'ections  of  the  terminal  branches  of  the  fifth  pair 


318  NEW- FORMATIONS. 

of  nerves,  and  those  which  are  general  and  are  occasioned,  com- 
monly, by  the  intensity  of  the  local  disturbance.  The  local 
symptoms,  wliich  sometimes  are  the  only  ones,  indicate,  as  a 
rule,  the  commencement  of  the  disease;  the  affections  of  the 
nerves  usually  succeed  and,  apparently,  are  dependent  upon  the 
former ;  sometimes,  however,  these  are  the  first  to  appear,  and 
continue  to  be  the  only  symptoms.  The  general  symptoms  are 
the  last  to  make  their  appearance,  and  are  developed,  also,  during 
certain  periods  of  the  disease. 

The  local  symptoms  simulate  those  of  chronic  inflammation  of 
the  root-membrane,  and  the  existence  of  a  tumor  of  the  root- 
membrane  can  only  be  determined  as  probable  when  the  carious 
or  non-carious  tooth  has  become  loosened  and  dislocated,  since 
chronic,  circumscribed  suppurations  (Eiterungsherde)  produce 
these  results ;  even  the  occasional  consecutive  appearances  pre- 
sented by  the  gums,  as  swelling  and  suppuration,  occur  alike 
with  chronic  inflammation  and  Avith  tumors  of  the  root-mem- 
brane. An  acute  inflammation  of  the  periosteal  membrane  may 
quite  readily  be  discriminated  from  the  latter. 

The  progress  of  the  tumor  is  quite  slow,  being  prolonged 
during  many  months ;  there  are  exacerbations  in  the  inflam- 
matory symptoms,  sometimes  severe  pain  and  very  acute  sensi- 
tiveness which  is  manifested  in  chewing  or  by  contact  with 
anything.  Magitot  observed,  also,  a  certain  degree  of  disturb- 
ance of  vision  in  cases  complicated  with  orbital  neuralgia,  or 
tinnitus  aurium  and  partial  deafness  in  connection  with  neuralgia 
in  the  ear. 

Magitot,  in  an  appendix  to  his  monograph,  gives  a  descrip- 
tion of  polypi  of  the  dental  periosteum,  accompanying  caries, 
which  are  attached  by  means  of  a  pedicle  to  the  neck  of  the 
tooth  and  are  composed  of  the  same  tissue  as  the  normal  peri- 
osteum but  in  an  hypertrophic  condition ;  he  did  not  meet  with 
epithelium  or  myeloplaxes  in  these. 

These  polypous  outgrowths  upon  the  necks  of  teeth,  which 
occur  in  connection  with  caries,  indeed  tumors  upon  the  carious 
roots,  also,  are  especially  liable  to  be  .confounded  with  prolifera- 
tions of  the  gums,  Avhen  the  latter,  in  consequence  of  partial 
resorption  of  the  alveolus,  extend  to  the  neighborhood  of  the 


GUM.  319 

radical  apices,  become  inserted  between  the  roots  or  are  attached 
to  the  necks  of  the  teeth.  The  well-marked  papillary  structure 
of  the  proliferating  gum,  together  with  its  epithelial  covering, 
afford  ([uite  positive  grounds  for  its  distinction  from  the  former 
affection. 

Gum. — PapiUomata  of  the  gum  are,  essentially,  localized 
hypertrophies  of  the  papillary  portion  ;  generally  they  are  asso- 
ciated Avith  caries  and  are  located  upon  the  facial  surface  of  the 
gum;  their  diminutive  conical  elevations  form  dome-shaped  en- 
largements and  present  an  analogy  with  acuminate  condylomata. 
The  remarks  which  have  already  been  made  in  connection  with 
hypertrophy  of  the  gum  are  applicable  to  the  structure  of 
papillomata. 

Sometimes  proliferation  of  the  submucous  connective  tissue 
of  the  gum  coexists  with  that  of  the  papillary  portion,  in  which 
cases  the  tumors  acquire  larger  dimensions  and  firmer  consist- 
ence.* 

Fibromata  of  the  gum  occur  in  the  submucous  connective 
tissue  in  the  form  of  projecting,  superficially  smooth,  compact 


*  Suiter  (Guy's  Hospital  Reports,  series  iii)  reported  the  following  inter- 
esting case  from  the  praetice  of  W.  S.  Granger.  In  a  man  fifty-seven  years 
of  age,  the  upper  first  bicuspid  being  loose  was  removed ;  to  all  appearances 
the  tooth  was  sound,  as,  also,  was  the  surrounding  gur.".  Four  months  later, 
a  slight  unevenness  and  swelling  was  noticed  upon  the  same  side  of  the  palate, 
extending  from  the  inner  alveolar  margin  of  the  gum,  at  the  point  where 
the  bicuspid  was  located,  in  the  direction  of  the  arch  of  the  palate  and  cover- 
ing a  space  about  as  large  as  a  finger  nail.  While  smoking,  this  place  be- 
came sensitive  but  at  other  times  it  was  not  painful.  After  cauterization, 
distinct  papillae  were  developed.  Eleven  months  after  the  extraction  of  the 
bicuspid,  the  tumor  had  attained  half  the  size  of  a  walnut  and  spread  from 
the  alveolar  margin  upon  the  hard  palate  towards  the  median  line.  Its 
color,  a  creamy-white  (probably  from  the  exfoliation  of  the  epithelium),  con- 
trasted with  the  dark-purple  of  the  investing  mucous  membrane  and  between 
the  two  was  a  sharply  defined  boundary.  In  extirpating  the  tumor,  Cock 
found  it  so  firmly  united  with  the  periosteum  of  the  hard  palate  that  it  was 
necessary  to  remove  the  sound  portion  of  the  latter  which  was  beneath  the 
tumor.  Three  months  later  the  wound  was  closed  by  a  healthy  cicatrix ; 
there  was  not  the  least  trace  of  glandular  swelling  and  no  recurrence  of  the 
tumor.  Two  small  pieces  of  bone  exfoliated,  probably  in  consequence  of  the 
separation  of  the  periosteum  and  the  free  cauterization.  The  tumor  was 
composed  of  fibrous  tissue,  and  its  outer  surface  presented,  everj' where, 
large,  closely  packed  pa})illa3. 


320  NEW  -  FORMATIONS. 

tubercles,  which  sh)pe  away  towards  the  surrounding  tissues  ; 
they  are  by  no  means  of  rare  occurrence,  especially  those  of 
smaller  dimensions,  and  are  composed  of  firm  bundles  of  con- 
nective tissue  with  numerous  interlacements,  and  imbedded  cells. 
Linhart*  extirpated  a  fibroma  of  the  submucous  connective 
tissue,  nearly  as  large  as  a  hen's  egg. 

The  sarcomata,  likewise,  have  their  seat  in  the  submucous  con- 
nective tissue  of  the  gum ;  they  project  in  the  form  of  tolerably 
firm  tumors,  as  large  as  a  pea  or  bean,  and  inclose,  in  their 
outermost  layers,  roundish,  in  the  deeper,  spindle-shaped  cells, 
together  with  a  scanty,  fibrillated  basis-substance. 

Angiomata  (vascular  tumors)  are  of  rare  occurrence  and  some- 
times ojiverise  to  hemorrhage  which  endangers  life.  Saltert  re- 
ported  a  new-formation  of  this  kind,  which  was  composed  of 
numerous  convoluted  bloodvessels  and  connective  tissue.  The 
surface  of  the  tumor,  which  was  lobulated,  located  upon  the  neck 
of  a  tooth  and  as  large  as  the  berry  of  the  common  winter 
cherr}',  was  covered  with  papillae  like  those  of  the  gum  and 
with  epithelium.  The  latter  condition  serves  to  indicate  that 
the  new-formation  was  seated  in  the  submucous  connective  tissue 
of  the  gum  and  not,  as  alleged,  in  the  dental  periosteum. 

Epithelial  cancer  sometimes  occurs  primarily  in  the  gum  and 
generally  is  met  with  in  the  vicinity  of  the  molars.  First  of 
all,  minute  knotty  elevations  are  developed,  which  increase  in 
number  and  extent  and  spread  to  the  submucous  connective 
tissue,  dental  periosteum,  alveolus,  and  alveolar  process.  The 
epithelium  undergoes  notable  proliferation  and  imparts  a  brighter 
color  to  the  knots;  it  also  dips  down  to  a  considerable  depth 
into  the  substance,  where  the  familiar  rosette-shaped,  nest-like 
groups  of  flattened,  often  distinctly  ribbed  cells  are  met  with. 
Sometimes  the  papillre  of  the  gum,  also,  grow  considerably  in 
length  and  breadth,  and  the  cancer  acquires  the  appearance  of 
a  succulent  Avart  which  finally  ulcerates.  SchuhJ  observed  the 
origin  of  the  epithelial  cancer  upon  the  internal  buccal  surface, 

*  Wurzburger  med.  Zcitschr.,  Bd.  II. 

t  Trans,  of  the  Path.  Soc  ,  1854. 

X  Pathologic  und  Thcrapie  der  Pseudoplasmon. 


MUCOUS    MEMBRANE    OF    THE    MOUTH.  321 

usually  in  the  vicinity  of  the  last  molars.  Here,  also,  he  says, 
it  maintains,  for  a  time,  the  character  of  the  broad  (flach)  cancer, 
that  is,  of  a  form  of  cancer  which  increases  only  in  its  extent  of 
surface,  not  in  depth,  remains  superficial,  therefore,  resemblino- 
a  graijulating  surface,  and  slowly  destroys  the  organic  parts.* 

Medullary  cancer  sometimes  spreads  to  the  gum  from  the 
adjacent  parts,  but  it  can  hardly  be  said  to  affect  the  former 
primarily. 

Mucous  Membrane  of  the  Mouth. — Notably  projecting  pro- 
liferations of  this  membrane  are  met  with,  now  and  then,  in  con- 
nection with  caries,  adjacent  to  the  lingual  surface  of  the  gum, 
particularly  in  the  vicinity  of  the  upper  molars;  they  contain  a 
layer  (one-half  centimetre  and  upwards  in  depth)  of  acinose 
glands  beneath  a  turgid  corium,  and  are  to  be  regarded  as  ade- 
nomata. The  importance  of  these  glandular  enlargements,  in  con- 
nection with  the  carious  process,  will  be  considered  further  on. 

A.  Forsterf  not  infrequently  observed  a  swelling  of  the  glands 
of  the  oral  mucous  membrane,  together  with  a  transformation 


*  Under  this  head  is  to  be  classed  the  remarkable  case  of  a  papiHary 
tumor  upon  the  alveohir  margin  of  the  right  lower  jaw,  in  a  man  eighty 
years  old,  which  came  under  the  observation  of  W.  Fergusson,  and  was  re- 
ported by  J.  A.  Salter  (Guy's  Hospital  Reports,  series  iii).  The  tumor, 
having  the  appearance  of  long-macerated  flesh  which  had  acquired  a  bad 
color,  was  removed,  and  fourteen  days  later  it  returned  presenting  the  same 
character,  so  that  it  became  necessary  to  repeat  the  operation.  The  patient 
died  from  old  age,  as  it  was  alleged,  soon  after  this  operation.  It  was  stated 
that  there  was  no  swelling  of  the  lymphatic  ghmds  in  the  neighborhood,  and 
the  tumor  was  unconnected  with  the  bone.  Salter  found  an  aggregation  of 
papilJEe,  pointed  at  their  free  extremities  and  united  together  at  their  bases, 
many  of  which  were  nearl}'  an  inch  long  and  resembled  the  papillae  filiformes 
of  the  tongue,  while  others  were  similar  to  the  papillae  fungiformes.  The 
mass  consisted  almost  entirely  of  pavement-epithelium,  and  the  cells  were 
also  arranged  in  the  form  of  birds'  nests,  as  in  epithelial  cancer.  The 
elongated  filiform  papillaB  were  striped  longitudinally  and  were  readily 
separable  into  smaller  hairy  processes ;  their  edges  were  composed  of  very 
compact  cells  which  by  themselves  presented  no  evidence  of  an  epithelial 
character,  while,  on  the  contrary,  the  more  superficial  cells  were  decidedly 
epithelial.  He  was  unable  to  distinguish  any  limiting  layer  of  the  papilla, 
nor  any  vascular  loops  in  them.  The  basis  of  the  new-formation  was  com- 
posed of  fibrous  tissue. 

t  Handbuch  der  pathol.  Anat.,  2  Aufl.,  Bd.  II. 

21 


322  NEW- FORMATIONS. 

of  the  glandular  secretion  into  a  mucilaginous  or  colloid  mass. 
When  the  acini  are  confluent,  cysts  are  developed,  containing  a 
mucilaginous  mass  in  Avhich,  in  certain  cases,  larger  or  smaller 
calcareous  concretions  may  also  be  found  at  a  later  period. 
He  met  with  the  latter  tumors  also  adjacent  to  the  gum.  I  have, 
also,  repeatedly  observed  them  in  the  latter  location,  and  have 
found  the  mucous  glands  degenerated  in  the  manner  described; 
occasionally,  the  developnsent  progressed  to  the  formation  of 
3'oung,  gelatinous  connective  tissue. 

The  white  excrescences  upon  the  mucous  membrane  of  the 
cheeks,  lips,  and  palate,  described  by  Schuh,*  belong  to  this  cate- 
gory, in  the  opinion  of  Forster.  The  former  described  them  as 
white,  curved  folds,  which  project  from  one  to  four  lines,  are 
two  to  three  lines  broad,  and  may  acquire  a  length  of  over  an 
inch.  They  terminate  occasionally  in  discrete  knots  the  size  of 
millet-seeds.  Sometimes  several  folds  of  this  description  are 
found  in  close  proximity.  Their  outer  surface  is  tolerably 
smooth  or  minutely  granular,  and  their  consistence  like  that  of 
the  broad  condylomata.  They  are  never  painful.  Their  com- 
plete development  occurs  within  a  few  weeks.  In  two  cases, 
they  disappeared  spontaneously  in  a  few  months;  in  a  third, 
during  the  external  and  internal  use  of  iodine;  in  a  fourth,  the 
affection  had  lasted  several  years,  and  increased  slowly  ahvays 
in  a  uniform  manner.  The  affection  returned  after  extirpation. 
Schuh  did  not  investigate  them  very  closely,  and,  therefore, 
their  pathological  classification  is,  as  yet,  undecided. 

Alveolar  Processes. — It  has  been  customary  of  late  to  class 
epulis  with  the  diseases  of  bone,  and  to  understand  thereby 
tumors  growing  from  the  maxillar}^  periosteum,  particularly 
from  that  of  the  alveolar  processes,  and  from  the  bony  substance 
of  the  latter.  Virchowf  considers  it  best  to  employ  the  term 
epulis  only  in  a  topographical  sense,  to  signify  a  tumor  of  the 
alveolar  process.  This  restriction  of  the  term,  he  states,  is  con- 
venient in  that  it  enables  us  to  speak  of  epulis  sarcomatosa, 
myxomata,  &c. 

Epulis,  in  the  restricted  sense  of  an  affection  of  the  bone, 


*  Pseudoplasmen,  1854. 

f  Die  kraiikliuften  Gescluviilstc,  Bd.  II. 


ALVEOLAR    PROCESS.  323 

originates  in  an  irritated  condition  of  the  periosteum  and  bone. 
Traumatic  cau~^es,  e.g.,  crushing  and  splintering  produced  in 
extraction,  particularly  of  the  milk  and  permanent  bicuspids 
and  molars,  in  all  probability  give  origin  to  it  in  some  cases. 
Positive  proof  of  a  trauma  is  difficult  to  obtain,  however,  in 
man}'^  cases.  A  congenital  or  acquired  obliquity  of  one  or 
another  tooth  may  also  be  regarded  as  an  occasional  cause. 
Carious  roots  are  said  to  be  a  frequent  predisposing  cause. 

Schuh  regarded  epulis  as  a  local  affection  which  may  occur 
at  any  period  from  the  second  year  after  birth,  even  to  old  age, 
and  in  either  sex  or  with  any  habit  of  body.  It  occurs,  how- 
ever, more  frequently  in  young  persons.  Many  writers  assert 
that  it  is  of  more  frequent  occurrence  with  females  than  with 
males,  and  is  met  with  more  often  on  the  lower  than  on  the 
upper  jaw. 

The  tumor  is  distinguished,  in  situ,  as  a  firm,  immovable, 
convex,  knotty  protuberance  of  variable  size,  covei'ed  with  red- 
dened mucous  membrane;  it  spreads  over  one  or  more  teeth, 
dislocates  them  from  their  normal  positions,  and  loosens  them 
so  that  eventually  they  fall  out.  As  a  rule,  it  does  not  occa- 
sion any  pain  in  the  teeth,  nor  do  the  latter  present  any  per- 
ceptible anomaly  after  extraction.  Generally  its  site  is  in  the 
vicinity  of  the  teeth  which  have  multiple  roots. 

When  the  epulis,  in  the  course  of  time  which  may  be  pro- 
longed for  several  years,  has  attained  considerable  size,  so  that 
it  produces  a  notable  bulging  upon  the  facial  surface,  a  distor- 
tion of  the  nostril,  a  deviation  of  the  angle  of  the  mouth  and  of 
the  external  angle  of  the  eye,  and  spreads  upon  the  lingual  side 
as  well,  hemorrhages  easily  occur,  in  consequence  of  the  hyper- 
dum'ic  condition  of  th&  veins  of  the  tense  superjacent  gum,  and 
erosions  are  produced,  Avhich  result  in  ulcers  that  are,  sometimes, 
disgusting  in  appearance  and  emit  a  foul  odor.  If  the  disease 
be  neglected,  even  perforation  of  the  external  skin  may  ensue, 
a  portion  of  the  tumor  may  suppurate  and  then  life  itself  may 
become  endangered.  In  consequence  of  the  irritation  produced 
by  the  disease,  the  lymphatic  glands  in  the  superior  cervical 
region  sometimes  become  swollen. 

Epulis  fihromatosa   generally   has  a    firm,    compact,   tough, 


324  NEW- FORMATIONS. 

■^brous,  slightly  succulent  texture,  and  towards  its  broad  basal 
portion  presents  either  scattered  agglomerations  of  calcareous 
grains,  or  a  trabecular  new-formation  of  osseous  substance.  The 
fibrous  basis-substance  is  abundant,  and  there  are  bundles  of 
elongated  fibres  which  interlace  extensively.  The  long  diame- 
ters of  the  spindle-shaped  connective-tissue  cells  correspond 
with  the  direction  of  the  fibres.  Where  the  cells  have  several 
processes,  the  latter  unite  to  form  a  network.  Chain-like 
groups  of  granular  ovoid  cells  are  imbedded  in  the  parenchyma, 
where  they  form  numerous  layers.  The  agglomerations  of  cal- 
careous grains  are  surrounded  by  tough  fibrous  tissue;  the  cal- 
careous salts  may  be  extracted  by  means  of  the  proper  acids 
when  there  remains  the  organic  basis  of  the  grains.  In  such 
cases,  therefore,  the  process  of  bone  formation  progresses  merely 
to  the  stage  of  excretion  of  calcareous  salts,  but  in  compara- 
tively few  places  isolated  groups  of  bone-corpuscles  are  met  with. 

When  the  osseous  substance  of  the  base  of  the  tumor  is  an  out- 
growth from  the  periosteum,  retiform,  osseous  trabecular  are 
met  with,  imbedded  in  the  bundles  of  connective  tissue,  which 
become  less  conspicuous  towards  the  periphery  of  the  tumor 
(Atlas,  Fig.  136).  Isolated  groups  of  delicate  trabeculge,  also, 
are  found.  In  order  to  displ.ay  the  newly-formed  osseous  frame- 
work of  the  osteoid  tumor,  it  should  be  macerated. 

When  tumors  of  this  description  have  attained  considerable 
size,  it  is  also  found  that  separate  portions  acquire  a  gelatinous 
(myxomatous)  character,  and  in  these  portions  numerous  groups 
of  cells  are  discernible  within  a  delicate,  trabecular  stroma. 

The  submucous  connective  tissue  of  the  gum  is  in  immediate 
relation  with  the  epulis,  and  the  gum  is  subjected  to  considerable 
tension  as  the  tumor  continues  to  grow.  The  papillary  portion, 
notwithstanding  its  remarkable  mirror-like  smoothness,  may 
still  readily  be  identified  (Atlas,  Fig.  135). 

As  the  development  of  the  tumor  progresses,  the  gum  is 
stretched  to  such  a  degree  that  it  becomes  necrosed.  In  conse- 
quence of  the  unavoidable  irritation  and  foulness,  occasioned  by 
food,  liquids,  &c.,  purulent  infiltration  of  the  tumor  ensues  in 
connection  with  the  above-mentioned  oflfensive  ulceration,  a  con- 
dition of  things  which  may  lead  to  an  erroneous  interpretation 
of  the  tumor  as  one  of  a  cancerous  nature. 


ALVEOLAR    PROCESS. 


325 


In  cases  of  epulis  in  which  there  is  a  predominance  of  the 
sarcomatous^  to  the  exclusion  of  the  fibrous  element,  an  abun- 
dant cellular  structure  is  presented  to  view,  which  sometimes 
attains  such  a  preponderance  as  to  displace,  almost  completely, 
the  fibrillated  substance,  and  we  find  only  aggregations  of  large 
spindle-shaped  cells,  together  with  encapsulated  groups  of  round- 
ish cells,  generally  with  a  single  nucleus,  and  a  scanty  fibrillated 
substance.  There  is  a  notably  frequent  occurrence,  even  in  the 
fibrous  epulis,  of  flattened,  large  cells  which  present  variously 
shaped  processes,  a  minutely  granular  protoplasm,  and  inclose 
two,  twenty,  and  even  many  more,  oval  nuclei,  and  have  been 
described  by  Robin  as  myeloplaxes  (medullary  plates),  and  not 
as  cells;  he  found  these  in  normal  marrow,  particularly  in  that 
of  young,  growing  bone.  This  view,  however,  has  not  met  with 
very  general  acceptance.  Paget  called  these  formations,  multi- 
nucleated cells,  and  Virchow  designates  them  as  multi-nucleated, 
gigantic  cells.  Since  the  gradual  multiplication  of  the  nuclei  in 
a  series  of  these  elementary  organs  may  easily  be  traced,  and  a 
progressive  division  of  the  nuclei,  together  with  a  corresponding 
increase  of  the  protoplasm,  may  be  identified  with  very  high 
magnifying  powers,  and  since  there  is  nothing  to  indicate  the 
occurrence  of  casual  fusion  of  cells,  I 
consider  it  to  be  settled  that  they  origi- 
nate from  uni-nucleated  cells.  These 
flattened,  gigantic  cells  are  disposed  be- 
tween the  fusiform  cells  and,  frequently, 
fall  out  from  sections  of  the  tumor,  leav- 
ing corresponding  empty  spaces  (Fig.  91). 
Virchow  regards  them  as  heteroplastic 
formations  which  arise  from  the  pro- 
liferating elements  of  the  periosteum. 
This  heteroplasia,  according  to  him,  does 
not  involve  the  idea  of  malignancy,  even 
in  the  narrowest  clinical  sense;  at  all 
events,  he  is  not  aware  of  a  case  where 


Fig.  91.* 


y^m-i 


,..;.& 


*  Fig.  91  shows  a  section  from  an  epulis  sarcomatosa,  which  includes  in 
its  basal  portion  numerous  bony  spicules,  and  contains  in  its  fleshy  portion 
interdigitating  fusiform  cells  with  prominent  nuclei,  which,,  also,  surround 


326  NEW- FORMATIONS. 

the  process  extended  by  rnetastiisis  from  an  original  epulis  to 
internal  organs,  or  where  it  spread  even  to  the  nearest  lym- 
phatic glands. 

Several  varieties  of  epulis  sarcomatosa  are  distinguished. 
According  to  their  seat,  E.  Nelaton*  has  divided  such  tumors 
into  two  forms,  which  he  describes  as  pcri-osseuse  on  sous-peri- 
ostique,  and  as  intra-ossnise,  both  of  which,  in  his  opinion,  arise 
from  an  hA-pergenesis  of  the  medulla  of  the  bone.  These  two 
varieties,  in  the  opinion  of  Yirchow,  evidently  correspond  with 
the  two  forms  of  sarcoma,  the  periosteal  and  myeloid.  He  op- 
poses, with  reason,  the  view  of  Nelaton,  that  they  are  produced, 
invariably,  by  an  hypergenesis  of  the  medulla  of  the  bone,  since, 
he  says,  it  is  not  uncommon  for  the  tumor  to  have  an  osseous 
basal  portion  which  forms  a  considerable  elevation  beyond  the 
surface  of  the  original  bone,  and  the  softer  portion  of  the  tumor, 
which  contains  the  myoloplaxes,  becomes  separated  from  the 
surface  of  the  old  bone  by  this  bony  basis.  I,  also,  have  had  the 
opportunity  of  observing  such  an  osteoid  sarcoma,  but  am  of  the 
opinion  that  our  present  knowledge  in  regard  to  the  occurrence, 
propagation,  and  signification  of  the  multi-nucleated,  gigantic 
cells  is  still  too  defective  to  enable  us  to  form  a  definite  idea  in 
respect  to  their  origin. 

If  Ave  examine,  before  and  after  maceration,  a  sarcoma  which 
grows  in  the  medulla  of  the  bone,  together  Avith  the  tooth  which 
is  inserted  into  the  tumor,  we  find  that  the  cancelli  of  the  re- 
maining bony  framcAvork  are  dilated  and  filled  Avifh  a  tolerably 
consistent  new-formation.  The  latter  contains  numerous  ovoid 
and  fusiform  cells,  besides  bloodvessels  Avith  thick  Avails,  Avhose 
external  coats  swarm  with  proliferating  cells.  The  osseous 
trabeculfe  Avhich  are  still  retained  in  the  new-formation  undergo 
a  gradual  resorption  Avhich,  also,  visibly  involves  the  alveolus  of 

multi-nucleated,  gigantic  cells,  so-called  myeloplaxes.  The  latter  are  flattened, 
present  short,  blunted  or  pointed  processes,  vary  in  size,  and  inclose,  within 
a  ]irotoplasni  of  niinuto  granules,  numerous  oval  and  multifariously  indented 
nuclei.  The  transition  iVom  uni-nucleated  ovoid  to  the  large  cells  may  be 
followed  out.  The  section  shows  several  vacuities,  the  sites  of  gigantic  cells 
which  have  fallen  out.  Magnified  four  hundred  diameters. 
*  Virchow,  op.  cit.,  p.  313. 


ALVEOLAR    PROCESS.  327 

tlie  tooth.  If  the  new-formation  comes  into  contact  wltli  the 
periosteum  of  the  root,  after  the  complete  resorption  of  a  portion 
of  the  alveolus,  the  tooth,  of  course,  becomes  loosened  in  its 
socket. 

When  the  epulis  is  confined  to  a  small  portion  of  the  alveolar 
process,  the  operation  proposed  by  Salter,  to  extract  the  cor- 
responding teeth,  with  the  view  of  preventing  a  recurrence  of 
the  superficially-extirpated  tumor  by  means  of  the  resorption  of 
the  dental  alveolus  which  ensues  after  the  extraction,  may  some- 
times be  of  service.  In  many  cases,  however,  the  removal  of 
the  teeth  will  have  no  effect  in  inducing  the  involution  of  the 
tumor,  if  the  latter  be  a  myeloid  and  deeply  rooted,  and  the 
germs  are  allowed  to  remain  and  to  continue  their  development 
after  cicatrization  of  the  alveolus  is  completed.  Schuh  states 
explicitly'-  that  teeth  which  have  become  loosened  by  the  disease 
not  infrequently  are  extracted  before  the  patient  has  any  sus- 
picion of  the  existence  of  the  affection.  If  the  tooth  is  only  a 
little  loose,  we  may  be  assured  that  the  bony  alveolus  is  involved, 
and  the  tooth  should  be  extracted  ;  the  degenerated  portions 
should  be  excised  with  a  strong  knife  and  the  cut  surfaces 
thoroughly  scraped  or  carefully  singed  Avith  the  actual  cautery. 
He  lays  stress,  therefore,  upon  a  radical  extirpation. 

Osteomata  or  exostoses  of  the  alveolar  process  usually  are  con- 
sidered under  the  head  of  hypertrophies  in  the  manuals  of  den- 
tistry'. They  are  not  by  any  means  of  ver}''  rare  occurrence, 
and  are  met  with  frequently  in  the  cadaver,  in  more  or  less  ad- 
vanced stages  of  development. 

They  present  manifold  variations  in  size,  from  that  of  minute 
knots  to  that  of  excrescences  as  large  as  millet-seeds,  peas,  or 
beans;  the  latter  sometimes  coalesce  and  form  a  ridge  or  crest. 
The  diminutive  forms  often  disappear  during  life,  or  are  mistaken 
for  callosities  of  the  gum  and  are  not  recognized  except  upon 
the  skeleton.  They  are  less  likely  to  attract  the  attention  since 
they  occasion  no  annoyance.  Upon  the  alveolar  border  of  the 
labial  side  of  the  lower  jaw,  particularly  in  association  with  the 
firm  structure  of  the  jaws  and  teeth  in  elderly  people,  or  with 
closely-approximated  or  overlapping  teeth,  I  have  frequently 
found  tuberiform  excrescences,  two  to  three  millimetres  in  diam- 


328  NEW- FORMATIONS. 

eter  and  one  millimetre  thick,  which  were  truversed  in  a  per- 
pendicular direction  by  shallow  vascular  grooves,  were  very 
compact  and  only  in  very  rare  cases  presented  larger  measure- 
ments than  those  mentioned.  Coalescence  of  adjacent  nodosities 
is  not  uncommon,  in  which  cases  they  form  rounded  ridges  with 
hump-like  elevations  corresponding  in  locality  with  that  of  the 
different  dental  roots. 

Upon  the  lingual  side  of  the  lower  jaAV,  the  excrescences  at- 
tain larger  dimensions.  The  case  illustrated  in  the  Atlas,  Fi";. 
138,  shoAvs  compact  protuberances  of  bony  substance  which  pre- 
sent depressions  and  grooves  upon  their  smooth,  rounded  outer 
surfaces,  are  attached  by  a  broad  base  to  the  alveolar  process, 
just  beneath  its  margin,  and  are  located  opposite  the  bicuspids 
and  first  molars.  The  anterior  segment  of  the  maxillary  arch 
presents  no  exostosis,  and  upon  the  posterior  segments,  opposite 
the  second  molars  and  wisdom  teeth,  there  is  merely  a  ridge  of 
bone.  In  this  case,  the  exostoses  attained  a  diameter  of  hardly 
more  than  five  millimetres,  but,  in  another  case,  which  we  ob- 
served, they  were  considerably  larger.  In  the  latter  case,  there 
are  two  flattened  protuberances  upon  the  lingual  surface  of  the 
anterior  segment  of  the  maxillary  arch,  and  situated  behind  the 
lateral  incisor  and  canine  on  either  side  ;  there  are,  also,  two 
large  osteomata,  one  behind  the  bicuspid  and  first  molar  on 
either  side.  The  surface  of  the  osteoma  upon  the  right  side, 
which  measures  sixteen  millimetres  in  its  antero-posterior  diam- 
eter, is  smooth,  that  of  the  one  on  the  left  side,  with  a  diameter 
of  nineteen  millimetres,  is  traversed  by  perpendicular  grooves 
and  has  a  diameter  of  seven  millimetres  fiom  above  downwards. 
A  bony  ridge  extends  upon  either  side  along  the  lingual  surface 
of  the  alveolar  process,  from  the  large  exostoses  to  the  vicinity 
of  the  second  and  third  molars. 

I  have  met  with  osteomata,  appearing  as  if  they  had  been 
dropped  upon  the  alveolar  process  of  the  upper  jaw,  only  upon 
the  facial  surface  and  corresponding  to  the  localities  of  the 
canines,  bicuspids,  and  molars.  They  occur  either  in  the  form 
of  an  exuded,  as  it  were,  quite  consistent  and,  therefore,  quite 
white  osseous  mass  which  covers  the  alveolar  process  near  its 
margin,  or,  especially  in  the  region  of  the  molars,  in  the  form 


ALVEOLAR    PROCESS.  329 

of  pad-like  elevations,  the  size  of  a  lentil  or  even  larger,  which 
have  a  broad  base,  sometimes  project  beyond  the  alveolar  mar- 
gin, are  polished  upon  their  outer  surface  and,  now  and  then, 
are  traversed  by  several  vascular  grooves.  In  other  cases,  we 
find  merely  a  projecting  bony  ridge  which  unites  the  alveolar 
borders. 

Microscopic  examination  of  sections  of  these  growths  shows 
that  they  are  composed  of  the  compact  osseous  tissue  of  the 
cortical  substance.  The  lamellae  are  disposed  in  the  form  of 
arches  and  are  very  uniform  ;  the  vascular  canals  form  a  series 
of  flattened  arcs,  with  oblique  anastomoses,  and,  generally,  are  of 
small  diameter  (Fig.  92).    Hence  arises  the  notable  compactness 


and  white  appearance  of  the  osteoma.  The  alveoli  are  not  in- 
volved in  the  process  and,  therefore,  the  teeth  retain  their  normal 
position. 

Close  examination  of  the  osteoma  establishes  beyond  doubt 
the  fact  of  an  interstitial  development  of  hone  in  many  places. 
We  find,  namely,  interposed  bone-corpuscles,  isolated  in  some 
cases  and  grouped  together  in  others,  which  are  separated  from 
the  original  systems  by  a  hyaline,  indented  or  festooned,  dividing 

*  Fig.  92  shows  an  osteoma  from  the  lingual  wall  of  the  ffiterior  segment 
of  a  lower  jaw.  The  tumor  forms  an  elevation  upon  the  wall,  seven  mil- 
limetres in  height,  rises  abruptly  upon  one  side  and  upon  the  other  presents 
a  more  gradual  slope.  Its  surface  is  smooth,  the  osseous  tissue  throughout 
is  compact  like  that  of  the  cortical  substance  of  the  bone.  The  narrow 
Haversian  canals  are  disposed  at  tolerably  uniform  distances  from  each 
other,  and  their  direction  corresponds  with  the  arched  formation  of  the 
tumor.  The  commencement  of  the  spongy  tissue  is  shown  at  the  broad  base 
of  the  tumor.     Magnified  three  diameters. 


330  NEW- FORMATIONS. 

layer.  The  extent  of  these  new  interstitial  systems  is  variable; 
they  are  wanting  in  uniformity  and  are  disposed  around  the 
vascular  canals,  or  penetrate,  are  wedged  in,  as  it  were,  between 
the  rows  of  the  old  systems  -which,  frequently,  present  a  granular 
cloudiness  and  correspond  with  parts  in  which  resorption  has 
begun. 

The  peripheral,  very  compact  zones  of  the  superficially  smooth 
osteomata  not  infrequently  contain  elongated  bone-canaliculi 
which  extend,  in  nearly  parallel  rows,  from  the  interior  towards 
the  periphery,  in  a  direction  oblique  to  that  of  the  tangential 
planes.  Tliey  are  wider  than  the  ordinary  bone-canaliculi,  pursue 
a  straight  course,  bifurcate  at  acute  angles,  at  one  extremity  are 
in  immediate  connection  Avith  the  bone-corpuscles  and  terminate, 
in  free  extremities  at  the  periphery,  I  am  undecided  whether 
or  not  they  have  any  connection  with  Sharpey's  fibres.  "We 
have  become  acquainted  with  quite  isomorphous  (isomorphe) 
canaliculi  in  hypertrophic  cement,  and  in  both  instances  they 
give  to  the  corresponding  portion  of  the  bone  an  obliquely- 
striped  appearance,  recognizable  even  with  quite  low  magnifying 
powers. 

The  origin  of  these  localized  proliferations  of  osseous  sub- 
stance, which  are  ushered  in  by  an  hyperplastic  condition  of  the 
periosteum  of  the  alveolar  process,  is  still  undetermined.  The 
fact  already  mentioned,  that  they  are  found  in  connection  with 
powerful  jaws  and  strong  sets  of  teeth,  or  with  closely-set  or 
overlapping  teeth,  suggests  the  supposition  that  the  primary 
irritation  is  induced  by  the  act  of  mastication  which,  in  these 
cases,  is  conducted  with  such  force  as  to  produce  an  undue  facial 
displacement  of  the  teeth  in  the  upper  jaw,  especially  of  the 
bicuspids  and  molars,  and  an  abnormal  lingual  displacement  of 
those  in  the  |ower  jaw.  With  this  view,  the  classification  of  the 
osteomata  would  become  evident.  Syphilis,  abundant  deposits 
of  tartar,  or  caries  take  no  part  in  their  production. 

They  require  treatment  in  exceptional  cases  only  on  account 
of  their  excessive  size.  They  do  not  give  rise  to  pain.  With 
very  large  tumors  upon  the  lingual  surface  of  the  lower  jaw,  the 
movements  of  the  tongue  are  interfered  with.     The  pectinated 


CYSTS    OF    THE    JAWS.  331 

proliferations  aflforcl  a  lodgeinent  for  pnrticles  of  food,  or  they 
prodnce  a  disfigurement.  They  may  also  form  a  hindrance  to 
the  ndaptation  of  sets  of  artificial  teeth.* 

The  spongy  tissue  of  the  alveolar  process  may,  likewise,  acquire 
an  hyperplastic  condition,  whence  an  enostosis  becomes  devel- 
oped, which  occasions  resoi'ption  of  the  alveolus,  dislocates  the 
tooth  from  its  normal  position  and,  eventually,  loosens  it  so 
much  that  it  fiills  out.  Tiie  enostosis  forces  the  lingual  and 
facial  walls  of  the  alveolar  process  farther  apart,  or  produces  a 
wider  separation  of  adjacent  teeth  and,  therefore,  exerts  an  ill 
effect  upon  the  entire  set  of  teeth. 

Cysts  of  the  Jaws. — Under  this  head  are  comprised  those 
hollow-formations  which  have  their  seat,  principally,  in  the  spongy 
tissue  of  the  alveolar  process,  embracing  upon  one  side  the  facial 
or  lingual  surface  of  one  or  more  roots,  while,  upon  the  other, 
as  they  increase  in  extent,  they  protrude  and  occasion  a  partial 
resorption  of  the  cortical  substance  of  the  bone. 

Carabelli  observed  cysts  in  both  the  upper  and  lower  jaw, 
without,  however,  recognizing  them  as  such  ;  he  described  them 
in  his  lectures  as  Hydrops  Antri  Highmori  and  cellulne  dentis 


*  Boiirdet  (L'lirt  du  Dontiste,  1757)  observed  five  or  six  cases  of  exostoses, 
of  ditlerent  sizes  up  to  that  of  a  pea,  upon  the  facial  wall  of  the  alveolar 
])rocess  of  both  the  upper  and  lower  jaw,  and  corresponding  in  locality  to 
tliat  of  the  incisors  and  canines.  They  occasioned  no  pain,  but  produced  a 
disfigurement.  They  returned  after  reiiioval  by  means  of  the  bone-forceps, 
but  disappeared  under  the  application  of  the  actual  cautery.  Tomes  remarks 
that  in  one  case  only  has  he  seen  hypertrophy  of  the  alveolar  process  attended 
with  inconvenience.  In  tliis  case  "  the  wliolc  of  the  alveolar  bone  was 
greatly  enlarged  ;  it  projected  upwards  in  the  lower,  and  downwards  in  the 
upper  jaw,  carrying  before  it  a  red  and  thickened  gum  and  concealing  within 
the  groove  formed  b_y  the  lingual  and  labial  portions  of  the  alveolar  ridge 
the  corresponding  surfaces  of  the  whole  of  the  teeth.  The  thickening  in  the 
front  part  of  the  mouth  was  so  great  that  the  lips  could  not  be  closed.  At 
the  back  part  of  the  alveolar  arch,  the  tiiickened  and  elevated  gums  of  the 
resp'^ctive  jaws,  although  mutualh'  flattened,  were  not  sufficiently  depressed 
by  the  action  of  the  jaws  to  allow  the  molar  teeth  to  come  in  contact.  The 
patient  was  a  half-witted  strumous  child,  whose  age  did  not  exceed  thirteen 
years,  and  whose  general  appearance  justified  the  assumption  that  the  disease 
was  but  a  local  manifestation  of  the  presence  of  a  strumous  diathesis."  No 
treatment  was  undertaken. 


332  NEW -FORMATIONS. 

and  from  them  lie  drew  a  conclusion  respecting  the  structure  of 
the  dental  periosteum  which  he  held  to  be  a  serous  membrane. 
Albrecht,*  in  nine  thousand  three  hundred  and  fifty  patients 
treated  by  himself,  met  with  only  seven  cases  of  cystic  forma- 
tion beneath  the  oral  mucous  membrane  upon  the  upper  and 
lower  jaws,  and  in  every  case  the  tumor  Avas  situated  behind  the 
bicuspids. 

Cysts  are  met  with  more  frequently  in  the  upper  than  in  the 
lower  jaw,  and  are  more  frequent  in  front  of  than  behind  the 
bicuspids,  t 

Since,  in  the  earlier  stages  of  their  development,  their  growth 
is  inconsiderable  and  their  increase  is  not  accompanied  by  any 
painful  sensations,  they  escape  observation  for  a  long  time,  until, 
in  consequence  of  a  more  rapid  increase  in  their  volume,  a  dis- 
tention and  bulging  of  the  maxillary  wall  ensues,  when,  for  the 
first  time,  they  are  perceived  by  the  patients.  They,  therefore, 
date  their  origin  from  the  time  Avhen  thev  first  observe  them 
and,  usually,  consider  them  to  be  tumors  of  the  teeth,  but,  ex- 
periencing no  pain  from  them,  they  do  not  apply  for  professional 
advice  in  regard  to  them,  until  it  is  found  that,  notwithstanding 
the  employment  of  emollients,  the  supposed  dental  tumors  in- 
crease in  size  and  show  no  disposition  to  disappear.  A  month, 
sometimes  six  months  and  more,  are  allowed  to  pass  from  the 
time  when  they  are  first  noticed,  and,  usually,  the  swelling  be- 
comes perceptible  even  externally  without,  however,  being  ac- 
companied by  redness  or  heat  of  the  skin.  Tlie  patients  are 
unable  to  assign  any  reasons  for  their  occurrence.  On  examina- 
tion, a  bulging,  from  the  size  of  a  hazel-nut  to  that  of  a  half 
walnut,  is  found,  usually,  upon  the  facial  wall  of  the  jaw;  it  is 
sharply  defined,  not  movable,  imparts  the  sensation  of  fluctua- 
tion, and  the  portion  of  the  maxillary  wall  which  is  protruded  by 
the  tumor  feels  like  parchment  and  crepitates;  the  tooth  corres- 
ponding to  the  most  prominent  part,  usually,  is  loosened,  and 
if  this  is  extracted,  the  contents  of  the  tumor  may  be  evacu- 
ated immediately  by  means  of  firm  pressure   upon  it  with  the 

*  Klinik  der  Mundkrankheiten. 

t  Heider  und  Wedl  in  the  Deutsche  Viertolj.  f.  Zahnheilk.,  1865. 


CYSTS    OF    THE    JAAVS.  333 

finger  or  after  puncture  of  the  wall  of  the  cyst  within  the  socket 
with  a  sharp  instrument.  The  fluid  which  escapes,  usually,  is 
albuminous,  viscid,  ropy,  yellowish,  and  clear. 

It  depends  upon  the  situation  of  the  cyst,  whether  the  outer 
or  inner  wall  of  the  jaw  is  distended  the  most ;  in  the  upper  jaw 
the  facial  wall,  usually,  is  the  one  involved.  When  the  cysts  of 
the  upper  jaw  are  developed  in  the  region  of  the  bicuspids  and 
molars,  they  project  even  into  the  antrum.  The  cystic  growths  in 
the  mucous  membrane  of  the  latter  will  be  considered  farther  on. 

Retarded  eruption,  especially  of  the  wisdom  teeth  in  conse- 
quence of  their  oblique  position  m^iy  be  the  predisposing  cause 
of  a  cyst-formation,  and  in  such  cases  the  question  arises  whether 
the  dental  sac  degenerates  into  a  cyst  Avhich  incloses  the  re- 
tarded tooth  or  whether  the  growth  of  the  tooth  in  an  abnormal 
direction  exercises  an  irritation  upon  the  surrounding  osseous 
substance  by  reason  of  which  the  latter  becomes  abnormally  de- 
veloped in  the  form  of  a  cyst.  Fackeldey*  mentions  two  instruc- 
tive cases,  from  Volkmann's  clinic,  of  very  extensive  cysts  of 
the  lower  jaw;  in  one  of  them,  the  right  wisdom  tooth  was  located 
upon  the  posterior  wall  of  the  cyst;  its  roots  were  imbedded  in 
a  peculiar  manner  and,  obviously,  in  consequence  of  a  deficiency 
of  space.  In  the  other  case,  the  crown  of  a  molar  (large?)  was 
found  projecting  into  the  cyst  from  the  lingual  side  of  its  ante- 
rior portion.  Its  roots  were  small  and  bent  to  one  side,  evi- 
dently in  consequence  of  a  want  of  space.  The  tooth,  finally, 
was  displaced  so  far  in  consequence  of  the  gradual  distention  of 
the  jaw  to  the  colossal  cyst,  that  it  was  located  at  least  an  inch 
and  a  half  below  the  level  of  the  rest  of  the  teeth  of  the  lower 
jaw. 

The  mode  of  development  of  cysts  of  the  jaw  has  not  yet  been 
determined,  and  further  anatomical  investigations  are  necessary 
in  order  to  elucidate  this  subject.  We  communicated,  in  the 
paper  cited  above  {vide,  also.  Atlas,  Figs.  183  and  13-4),  the 
results  of  an  anatomical  examination  of  a  cyst  in  the  alveolar 
process  of  the  upper  jaw,  behind  the  root  of  the  right  central 
incisor.     The  development  of  the  cyst  was  not  sufiiciently  ad- 

*  Inaugural  dissertation,  1869.     Deutsche  Vicrtelj.  f.  Zalinheilk.,  1870. 


334  NEW -FORMATIONS. 

vanoed  to  occasion  a  protuberance  upon  the  lingual  surface  of 
the  mucous  membrane  of  the  mouth,  and,  consequently,  it  had 
escaped  clinical  observation.  A  portion  of  the  cortical  layer  of 
the  lingual  Avail,  five  millimetres  in  extent,  was  Avanting,  and 
the  corresponding  portion  of  the  cyst  wall,  consequently,  came 
into  immediate  relation  with  the  subcutaneous  connective  tissue 
of  the  gum  ;  before  long,  therefore,  a  protuberance  would  have 
become  perceptible.  Moreover,  the  growth  of  the  cyst  towards 
the  osseous  tissue  was  indicated  by  the  fact  that  a  new,  minute 
cyst  Avas  located  laterally  upon  the  fibrous  layer  of  the  larger. 
Fackeldey,*  with  special  reference  to  this  case,  thinks  there  are 
grounds  for  considering  the  question  whether  the  cysts  of  the 
alveolar  process,  which  are  lined  with  a  membrane,  are  not  due 
to  an  anomaly  of  development,  a  degeneration  of  the  dental 
sac  or  a  lateral  budding  of  the  enamel  germ.  Without  denying 
the  possibility  of  the  connection  of  cysts  of  the  jaw  Avith  reten- 
tion or  follicular  cysts,  it  may  be  observed,  however,  in  objec- 
tion to  this  vicAV  that  both  simple  and  compound  cysts  with  a 
fibrous  lining  are  met  with  in  other  bones,  and  the  cysts  in  the 
upper  jaw%  especially,  are  developed  commonly  upon  its  facial 
side,  a  locality  Avitli  which  the  occurrence  of  follicular  or  reten- 
tion cysts  is  scarcely  compatible. 

In  several  cases,  I  have  found  the  lining  membrane  of  the  cyst 
tough,  compact,  and  coated  upon  its  internal  surface  with  a 
layer  of  epithelium,  consisting  of  several  laminae  of  flattened, 
nucleated  cells  which,  frequently,  interlocked  with  one  another  by 
means  of  blunt  processes.  These  cells  are  the  organs  of  pro- 
duction of  the  serous,  viscid  or  gelatinous  fluid,  while  the  con- 
tinuous proliferation  of  the  fibrous  membrane,  which  is  furnished 
with  wide  bloodvessels  Avitli  thin  walls,  occasions  the  gradual 
resorption  of  the  bone.  Sometimes,  also,  the  cysts  become  the 
seat  of  an  inflammatory  process  and,  in  such  cases,  contain  a 
puriform  fluid. 

When  the  cyst  attains  such  magnitude  as  to  invest  several 
teeth,  extend  beyond  the  limits  of  the  alveolar  process  and  occa-. 
sion  a  resorption  of  its  spongy  tissue,  the  alveoli  of  the  corre- 

*  Op.  cit. 


OSTEOPHYTES    UPON    TUE    JAWS. 


335 


Fig.  93.* 


spending  teeth  become   involveil   simultaneously,  the  latter  are 
loosened,    dislocated,   and   their    connection   Avith    the    alveolar 
borders    is  broken.      The    re- 
sorption of  the  bone  occasioned 
by  the  extension  of  the  cyst,     ^. 
takes    place    upon     both     the 
facial  and  lingual  surface,  and     a 
effects     a     not    inconsiderable     ;, 
breach  in  the  substance  of  the 
bone  (Fig.  93).     The  margins 
of  the  parts  where   resorption 

(usure)  has  taken  place,  are  serrated,  the  distended  facial  wall  is 
transparent,  thin  as  tissue-paper,  is  perforated  by  numerous, 
minute  foramina  for  the  passage  of  vessels  and,  upon  its  inter- 
nal surface  towards  the  cavity  of  the  cyst,  presents  extensive 
erosions,  the  resorption  excavations  which  have  frequently  been 
mentioned  in  the  preceding  pages. 

Cysts  can  only  be  confounded  with  other  affections  which 
occasion  swellings  in  the  jaws,  as  enchondromata,  sarcomata, 
myxomata,  abscesses,  and  Avith  collections  of  fluids  in  the 
antrum.  An  abscess,  however,  may  be  distinguished  by  its 
acute  course,  and  by  the  fact  that  the  tumor  formed  by  it  is 
never  so  sharply  defined  as  is  the  case  with  cysts  ;  with  dropsy  of 
the  antrum,  the  distention  of  the  facial  wall  of  the  jaw  is  more 
uniform  always  than  it  is  with  cysts.  In  some  cases,  the  diag- 
nosis cannot  be  determined  accurately  until  after  an  operation. 

Osteophytes  upox  the  Jaws. — Sometimes,  in  consequence 
of  diseases  of  the  teeth  and,  particularly,  of  chronic  inflamma- 
tion of  the  root-membrane,  an  irritation  is  induced  in  the  maxil- 

*  Fig.  93  ^hows  a  cyst  of  the  right  upper  jaw,  embracing  in  its  extent  both 
incisors  and  the  canine.  View  from  the  cavity  of  the  mouth.  It  has  an 
oval  form  and  a  long  diameter  of  two  centimetres  ;  internally  it  is  limited  by 
tlie  incisive  foramen  (a),  and  externally  by  the  cicatrized  alveoli  of  the  bicus- 
pids (6).  The  labial  wall  is  distended  like  a  bladder  (c).  Considerable  de- 
struction of  tissue,  which  is  defined  by  a  sharply  cut  outline,  has  occurred  upon 
the  hard  palate.  A  portion  of  the  alveolar  process,  corresponding  with  the 
two  incisors  and  canine  (d),  still  remains  unaOected  by  the  process  of  resorp- 
tion. The  internal  surface  of  the  cavity  of  the  cyst  is  smooth  and  perforated 
like  a  sieve.  Natural  size.  (For  the  use  of  this  specimen  the  author  is  in- 
debted to  Dr.  Friedlowski.) 


336 


NEW -FORMATIONS. 


lary  periosteum,  wliich  is  attended  by  its  tumefaction  and  sen- 
sitiveness, occasions  consecutive  oedema  and,  not  infrequently, 
gives  rise  to  the  formation  of  an  osteophyte  of  a  fine  spongy 
texture. 

If  a  series  of  macerated  jaws,  which  have  contained  carious 
teeth,  be  examined,  several  of  these  growths  will  usually  be 
found,  in  the  form  of  cribriform,  unyielding  lamellse,  generally 
adherent  to  the  facial  wall,  more  commonly  to  that  of  the  lower 
jaw,  and  distinguished  by  a  quite  bright  color.  When  peeled 
off  and  examined  in  thin  sections  they  prove  to  be  young  osseous 
substance.  They  are  located,  almost  always,  upon  the  posterior 
segment  of  the  jaw,  are  of  very  variable  extent  and  present  very 
irregular  outlines ;  their  thickness  varies  from  one-quarter  to 
one  millimetre.  They  occur  in  isolated  patches  and,  occasion- 
ally, spread  over  the  entire  surface  of  the  maxillary  wall. 

The  period  of  puberty,  together  with  the  retarded  eruption  of 
the  wisdom  teeth,  appear  to  be  especially  favorable  for  the  de- 
velopment of  osteophytes,  and,  wdien  associated  with  an  incom- 
plete growth  of  the  jaws,  they  are  to  be  connected  with  unusual 
succulence  of  the  periosteum. 

The  case,  illustrated  on  page  202,  of  partial  necrosis  of  the 
loAver  jaw,  which  occurred  in  connection  with  the  eruption  of 
the  wisdom  tooth,  was  accompanied  by  an  extensive  osteophyte- 
growth  that  spread  over  the  lingual  wall  of  the  jaw.  Very 
delicate,  branching,  separate,  osseous  trabeculae,  first  of  all, 
make  their  appearance;  these  increase  in 
size  and  unite  with  one  another.  The  la- 
mellae formed  in  this  way  are  always  per- 
forated with  sharp-edged  foramina  wdiich 
lead  to  the  vascular  canals  upon  the  sur- 
face of  the  jaw.  As  the  layers  increase  in 
thickness,  they  are  disposed  one  over  the 
other  like  the  tiles  on  a  roof,  and  are 
"^  marked  with  manifold  tortuous  grooves  and 

indentations,  which  give  to  tlie  whole  the  appearance  of  a  re- 
markably fine  filagree  work  (Fig.  94). 

*  Fig.  94  shows  a  section  from  an  osteophyte,  with  a  delicate  spongy  tex- 
ture, which  forms  an  excrescence  upon  the  smooth  facial  wall  of  the  lower 


Fig.  94  * 


ENOSTOSES    IN    THE    JAWS.  337 

Extensive,  thick  osteophytes,  developed  in  association  with  the 
symptoms  of  chronic  periostitis,  are  met  with  in  connection  with 
phosphornecrosis  of  the  jaws.  Primarily  (Lorinser,  Geist),  they 
have  a  fine  spongy  texture,  and  gradually  they  become  compact ; 
finally  a  new  bony  shell  is  formed,  while  the  original,  encapsulated 
bone  becomes  necrosed.  With  exacerbating  symptoms,  suppura- 
tion and  sanious  ulceration  (Verjauchung)  occur  upon  the  surface 
towards  the  necrotic  bone,  and  cloacre  are  formed  in  the  osteo- 
phyte, by  which  its  continuity  is  interrupted.  A  well-marked 
case  of  a  newly  formed  bony  shell,  which  is  separated  from  the 
necrotic  lower  jaw,  is  illustrated  in  the  Atlas,  Fig.  137.  The  shell 
presents  fenestrated  openings,  the  result  of  ulceration  ;  notwith- 
standing the  latter  process,  the  processes,  grooves,  tubercles  and 
spines,  and  even  the  mental  foramen,  are  seen  to  have  been  formed 
anew.  The  specimen  was  taken  from  a  woman,  twenty-two  years 
of  age,  who  had  worked  for  twelve  years  in  a  match  factory  and 
Avho  came  under  the  treatment  of  Dr.  Lorinser,  on  the  30th  of 
March,  1847.  The  disease  had  already  existed  for  six  months. 
She  died  from  tuberculosis  on  the  27th  of  August,  1847. 

Enostoses  in  the  Jaws. — Virchow*  proposes  to  limit  the 
term  enostosis  to  certain  osseous  growths  which  are  developed 
from  the  medulla  in  the  interior  of  bones  ;  he  met  with  only  one 
case,  a  porous  enostosis  in  the  spongy  extremity  of  the  tibia  of 
a  child.  He  also  includes  under  this  head  the  corps  osseux 
encystes  of  Cruveilhier  which  are  distinguished  by  their  great 
compactness.  As  the  latter  new-formations  are  of  extremely 
rare  occurrence  and  frequently  escape  observation  on  account 
of  their  dirainutiveness,  our  knowledge  with  reference  to  their 
origin  and  development  is  still  defective. 

Schuh  has  described,  under  the  head  of  rare  new-formations, 
a  bony  tumor  of  the  left  upper  jaw  in  a  girl  fourteen  years  of 

jiiw,  where  a  fistulous  opening  from  a  tooth  (r/)  is  perceptible.  The  new- 
formation  displaj's  extremely  delicate,  shallow,  channel-like,  vascular 
grooves  which  run  in  various  directions,  interlace  in  a  retiform  manner  and 
inclose  minute  lamellas  of  osseous  tissue.  Magnified  fifteen  diameters. 
(Viewed  with  oblique  light.) 
*  Kranlvh.  Geschwiilste,  II. 

22 


338  NEW -FORMATIONS. 

nge,  ■which  is  to  be  consiJered  as  a  spongy  enostosis.*  The  im- 
movable new-formation,  the  size  of  a  hen's  egg  and  of  bony 
hardness,  originated  in  the  diploetie  structure  and  not  from  the 
external  surface  of  the  bone,  pressed  the  anterior  surface  of  the 
]a\y  outwards  and,  by  its  continued  development  inwards,  en- 
croached upon  the  cavity  of  the  antrum,  a  small  portion  of 
which,  the  superior  and  posterior,  alone  remained.  It  spread 
from  the  incisors  on  the  left  side  as  far  as  the  maxillary  tuber- 
osity and  from  the  teeth  to  the  lower  margin  of  the  orbit ;  it 
was  not  painful  even  when  subjected  to  firm  pressure.  The 
teeth  of  the  affected  side  were  normally  arranged  and  firmly  im- 
planted within  the  distended  alveolar  process.  A  fragment  of 
the  bone  was  removed  and  presented  throughout  the  texture  and 
consistence  of  delicate  spongy  bone  and  was  composed  essen- 
tially of  a  retiform  trabecular  stroma  and  a  very  richly  vascu- 
larized connective  tissue  which  filled  the  vacuities  formed  by  the 
stroma.  These  vacuities  presented  no  marked  variations  in 
respect  of  size,  hence  the  newly  formed  bony  mass  preserved 
quite  a  uniform  compactness.  The  bone-corpuscles  varied  con- 
siderably, here  and  there,  were  more  closely  approximated  than 
in  normal  bone,  and  the  intermediate  substance  presented,  in 
places,  a  dirty-yellowish  color.  The  bloodvessels  were  of  com- 
paratively large  diameters.  The  girl  received  a  blow  in  the  face 
five  years  previously,  and  this  was  assigned  as  the  primary  cause 
of  the  tumor.  The  latter  was  extirpated,  the  wound  cicatrized 
rapidly  without  any  disfigurement,  and  there  was  no  recurrence. 

Forgetf  found,  in  the  socket  of  a  normal  canine  from  the 
upper  jaw  of  a  horse,  an  encysted  bony  tumor  entirely  uncon- 
nected with  the  tooth,  the  latter  being  displaced  towards  the 
median  line.  The  tumor  was  as  large  as  an  egg,  irregular,  and 
composed  of  bony  substance  merely  ;  the  cyst  was  undergoing 
suppuration. 

I  have  had  the  opportunity  of  examining  an  analogous  bony 
tumor  from  the  jaw  of  the  horse,  for  which  I  am  indebted  to 


"  Oesterr.  Zeitschrift  fiir  prakt.  Heilk.  und  Gesammelte  Abli.,  1862. 
f  Des  Anomalies  Dentaires,  1859. 


CHONDROMATA    OF    THE    JAWS.  339 

Prof.  Bruckmiiller.  It  was  encysted,  as  large  as  a  small 
hen's-egg,  of  the  density  of  ivory ;  its  outer  surface  was  tu- 
berculated,  indeed,  altogether,  one  would  be  inclined  to  con- 
sider the  case  as  one  of  an  encysted,  malformed  tooth.  On 
section,  however,  it  displayed  throughout  a  very  compact 
bony  tissue  traversed  by  numerous,  comparatively  thin,  vascular 
canals. 

As  neither  of  these  two  encysted,  compact,  bony  tumors  pre- 
sented any  dentinal  texture,  there  are  no  positive  grounds  for 
considering  them  to  be  dental  malformations,  and,  therefore,  I 
have  introduced  them  here  provisionally. 

Chondromata  of  the  Jaws. — Cartilaginous  tumors  are  de- 
veloped from  the  surface  of  the  bone  or  from  its  spongy  tissue. 
Their  growth,  as  a  rule,  takes  place  very  slowly,  and  particularly 
is  this  true  of  the  earlier  stages.  Pressure  upon  them  occasions 
no  painful  sensation.  They  are  consistent,  acquire  tolerably 
large  dimensions,  are  intermixed  with  a  considerable  amount  of 
fibrous  dense  tissue  so  that  merely  isolated  portions  display  in- 
terspersions  of  fibro-cartilage  and,  therefore,  are  to  be  desig- 
nated as  fibro-chond7'omata.  If  a  partial  ossification  has  taken 
place,  they  are  called  osteoid-cliondromata  in  which,  sometimes, 
calcification  occurs  only  in  circumscribed  spots.  If  the  oral 
mucous  membrane  becomes  necrotic  in  consequence  of  the  very 
marked  extension  of  these  tumors,  and  ulceration  ensues,  the 
discolored  ulcer  may  be  the  occasion  of  confounding  them  with 
cancer.  The  more  defined  outline  of  the  tumors  and  the  absence 
of  swelling  of  the  lymphatic  glands  serve  to  distinguish  them 
from  cancer.     Recurrence  after  extirpation  is  very  common. 

The  chondromata  (enchondromata)  which  take  root  in  the 
deeper  layers  of  the  bone,  especially  of  the  lower  jaw,  acquire  a 
malignant  nature  in  so  far  as  they  grow  quite  rapidly  and  give 
rise  to  notable,  supple,  even  fluctuating  swellings  from  liquefac- 
tion (Colliquescenz).  The  proliferating,  cartilaginous  tissue  un- 
dergoes a  marked  fatty  metamorphosis  and  solution  and,  in  the 
liquefied  localities,  becomes  bathed  in  a  yellowish,  viscid  fluid. 
The  cartilage  is  partly  hyaline  (Atlas,  Fig.  140),  but  it  is  also 
met  Avith  in  the  form  of  a  delicate  network.    As  the  cartilaginous 


810  NEW -FORMATIONS. 

tissue  encroaclies  upon  the  spongy  substance  of  tlie  bone,  it  in- 
duces a  wasting  of  the  osseous  lamellae 
and  even  of  the  alveolus;  the  correspond- 
ing tooth  becomes  detached,  and  in  the 
place  of  the  socket  is  found  the  cartilagi- 
nous adventitious  substance  (Aftersub- 
stanz).  (Fig.  95.)  The  pulps  of  the  teeth  are  not  perceptibly 
affected  by  the  proliferation. 

Fibromata  of  the  Jaws. — These  are  firm,  circumscribed, 
painless,  fibrous  tumors,  of  slow  growth,  which  are  prone  to 
ossify.  Sometimes  they  acquire  considerable  dimensions  and 
are  composed  of  conglomerate  knobs,  or  lobules  of  a  uniform 
texture.  According  to  Paget,  they  are  of  periosteal  or  enosteal 
origin.  Virchow  lays  stress  upon  the  heteroplastic  nature  of 
these  tumors  and,  especially,  of  the  enosteal  fibroma — hetero- 
plastic not  in  the  sense  of  malignant,  but  signifying  a  develop- 
mental process  which  gives  rise  to  a  tissue  of  a  different  type 
from  that  of  the  parent  tissue. 

Their  primary  seat  and  mode  of  development  are  unknown. 
When  superficially  located,  they  displace  the  cortical,  and  when 
located  more  deeply,  the  spongy  tissue;  partial  displacement  of 
the  alveolar  process,  also,  ensues,  and  the  teeth  are  dislocated 
from  their  normal  positions.  As  the  fibroma  continues  to  grow, 
the  cortical  tissue  undergoes  resorption,  leaving  a  portion  of  the 
former  covered  merely  by  the  mucous  membrane,  while  the  teeth 
are  loosened  and  detached,  from  the  extension  of  the  tumor 
beneath  them. 

In  a  circumscribed,  firm  fibroma  of  the  lower  jaw  (Fig.  96), 
fibrous  tissue  alone  was  found  towards  the  facial  and  lingual 
walls  of  the  bone,  while  the  central  portions  of  the  tumor  were 
occupied  by  particles  which  crackled  when  cut  with  the  knife, 


*  Fig.  95  shows  a  segment  of  the  ramus  of  a  lower  jaw  divided  horizontally, 
with  chondromatous  proliferation  in  the  spongy  substance.  The  two  roots 
of  the  first  molar  are  divided  transversely  ;  those  of  the  second  and  third 
molars,  together  with  their  alveoli,  are  wanting ;  a  succulent,  adventitious 
substance  occupies  their  places,  and  spreads  to  the  cortical  layers  of  the  bone. 
In  this,  numerous  oval  cartilage-cells  are  interposed  in  a  delicatel^'-fibrous, 
succulent  basis-substance.     Natural  size. 


FIBROMATA    OF    THE    JAWS.  341 

and  conveyed  the  sensation  of  roughness.  The  teeth  were 
notably  disphiced  in  consequence  of  the  resorption  of  the  cor- 
responding alveoli,  their  roots  were  inserted  directly  into  the 
newly-formed  mass,  the  fibrous  bundles  of  which  were  in  imme- 
diate connection  with  the  periosteal  membranes  of  the  roots  of 
the  corresponding  teeth.  Further,  as  the  fibroma  continued  to 
grow,  it  encroached  upon  the  limits  of  the  alveolar  process  which 
became  flexible. 

Fig.  96.* 


The  firm  substance  of  the  tumor  is  composed  essentially  of  a 
confused  mass  of  interlacing  bundles  of  connective  tissue,  be- 
tween which  narrow,  fusiform  cells,  following  the  course  of  the 
fibres,  are  interposed  at  tolerably  uniform  intervals.     The  cen- 


*  Fig.  96 — View  from  above  of  a  fibroma  of  the  lower  jaw,  from  a  patient 
fourteen  years  of  age.  The  jaw  was  resected  in  a  line  extending  from  the 
left  central  incisor  («)  along  the  right  horizontal  ramus  as  far  as  the  wisdom 
tooth.  Marked  displacement  of  the  teeth  was  occasioned  by  the  presence  of 
a  roundfd,  encapsulated,  firm  tumor,  6  4  centimetres  in  length,  4.5  centime- 
tres in  height  and  4  8  centimetres  in  breadth.  The  incisors  are  inclined 
obliquely  and  laterally.  The  canine  and  first  bicuspid  are  inclined  still  more, 
so  that  their  summits  are  directed  posteriorly  and  towards  the  median  line 
of  the  jaw.  The  second  bicuspid  (6)  is  separated  from  the  first  by  a  con- 
.siderable  interval,  in  consequence  of  the  proliferatiem  of  the  growth  between 
them,  and  the  masticating  surface  of  the  former  is  directed  anteriorly  and 
towards  the  median  line,  so  that  the  axes  of  the  two  bicuspids  cross  each 
other  at  nearly  a  right  angle.  The  first  molar,  which  is  carious,  presents  a 
slight  inclination  ;  the  second  molar  occupies  its  normal  position.  Two- 
thirds  natural  size.  (For  the  use  of  this  specimen  the  author  is  indebted  to 
Dr.  Weinlechner.) 


342  NEW-FORMATIONS. 

tral,  rough  spots  are  occupied,  in  places,  by  calcified  bodies, 

merely,  having  a  homogene- 

FiG.  97.*  1  •    1      1  1 

ous,  polished  appearance  and 


a  roundish,  often  spherical,  or 
an    elongated   form,   and   are 

■n  •>  invested    by   straight   fibrous 

~  ""     "^     ^  tissue.    In  other  places,  devel- 

'^•^1  ^'   ^       ("    i}}<     opment  has  progressed  to  the 

r 


-       formation  of  minute  osseous 


trabecul?e  of  various  forms, 
containing  jagged  bone-cor- 
~~  puscles  and  presenting,  upon 
their  peripheral  portions,  superposed  roundish  formations  (Fig. 
97). 

The  opinion  formerly  entertained  that  the  tumor  merely  dis- 
tends the  bone,  forces  the  external  layer  outwards,  is  disputed 
by  Virchow  on  the  ground  that  these  tumors  sometimes  attain 
such  magnitude,  that,  if  there  is  merely  a  distention,  it  would  be 
impossible  for  the  bony  shell  to  continue  unbroken.  It  is  much 
more  probable  that  a  new- formation  of  osseous  substance  takes 
place  upon  the  outer  surface  from  the  periosteum,  in  the  same 
manner  in  which  the  apposition  of  fresh  layers  ensues  in  growing 
bone.  In  the  case  cited,  a  complete  destruction  of  a  portion  of 
the  maxillary  wall  ensued  from  resorption. 

In  the  upper  jaw,  also,  the  fibromata  attain  quite  large  dimen- 
sions. Several  of  the  tumors  which  I  have  had  the  opportunity 
of  examining  contained  so  many  calcareous  deposits  that  the 
surfaces  of  sections  through  them  communicated  a  gravelly  feel- 

*  Fig.  97. — Section  from  the  central  portion  of  the  same  fibroma.  Straight 
bundles  of  fibrous  tissue  include  fusiform  cells  containing  oblong  nuclei,  and 
interlace  with  one  another.  Nests  of  ovoid  cells  are  imbedded  here  and 
there.  The  highly-refractive  calcified  portions  have  a  homogeneous  appear- 
ance and  a  roundish  or  elongated  form  {n).  The  isolated  trabecule  have 
the  character  of  young,  imperfectly-developed,  osseous  substance,  and  are 
surrounded  by  roundish,  nucleated  formative  colls  (A).  The  basis-substance, 
in  many  places,  has  a  coarse  granular  appearance;  the  jagged  bone-corpus- 
cles are  more  or  less  minute,  and  notched  cavities  filled  with  amorphous 
calcareous  salts  are  brought  into  view  here  and  there.  Magnified  400 
diameters. 


SARCOMATA    OF    THE    JAWS.  343 

insT.  Dr.  Friedlowski  showed  me  a  skull,  from  the  anatomical 
collection,  which  presented  a  breach  involving  the  facial  wall  of 
the  antrum  of  the  left  side,  a  portion  of  the  horizontal  plate  of 
the  superior  maxillary  bone,  and  of  the  inferior  turbinated  bone. 
The  second  molar  on  the  left  side  was  inclined  anteriorly,  and 
the  alveolus  of  its  anterior  facial  root  was  entirely  destroyed. 
The  alveolar  process  was  wanting,  from  the  canine  as  far  as  the 
second  molar.  The  breach  in  the  bones  extended  upwards  to 
the  vicinity  of  the  zygomatic  arch  and  was  bounded  everywhere 
by  sharp  edges.  The  tumor  which  occupied  the  smooth-walled 
cavity  corresponded  in  character  to  those  above  described,  ac- 
cordinor  to  the  statements  of  Dr.  FriedloAvski. 

Since  these  tumors  may  be  enucleated,  resection  may  be 
avoided  in  suitable  cases. 

Sarcomata  of  the  Jaws. — Without  taking  into  considera- 
tion those  which  are  developed  from  the  alveolar  process  and 
have  been  treated  of  in  the  preceding  pages,  sarcomata  are  of 
frequent  occurrence,  especially  in  the  lower  jaw,  in  the  form  of 
simple,  cysto-,  and  osteo-sarcomata. 

The  cysto-sarcoma  is  developed  in  the  spongy  tissue  of  the 
bone,  which  is  very  abundant  in  the  lower  jaw.  A  portion  of 
this  tissue  undergoes  complete  resorption,  and  in  its  place  occur 
sarcomatous  masses  and  cyst-like  cavities  of  various  dimensions, 
some  being  very  small  while  others  are  tolerably  large  (Atlas, 
Fig.  143).  The  larger  cavities  are  lined  with  a  separable,  con- 
nective-tissue membrane,  the  internal  surface  of  which  is  covered 
with  a  coating  of  small  cells..  Reddish,  succulent  proliferations 
of  a  roundish,  tuberculated,  nodulated,  mulberry-like  form,  pro- 
ject into  these  spaces  which  are  filled  with  a  thin,  yellowish, 
yellow-brownish,  or  a  thick,  viscid,  stringy,  ropy  fluid. 

In  the  case  illustrated  in  the  Atlas,  Figs.  142  and  143,  the 
sarcomatous  mass  has  a  quite  remarkable  structure.  There  is 
a  fibrillated  stroma  of  connective  tissue ;  in  this  are  imbedded 
vesicular  and  tubular  cavities  which,  here  and  there,  subdivide 
and  everywhere  are  lined  with  cylindrical  epithelium,  the  Avhole 
presenting  the  appearance  of  a  utricular  gland  with  many 
terminal  vesicles  as  if  detached  by  constriction.  These  adenoid 
masses  inclose  multifariously-siuuated  cavities  which  attain  con- 


344  NEW-FORMATIONS. 

siderable  size  in  consequence  of  the  secretion  of  a  fluid  on  the 
part  of  the  colunnar  epithelial  cells  and  their  proliferation. 
The  adenoid  structuie  is  apparent  -wherever  a  sarcomatous  mass 
is  to  be  seen,  and  is  wanting  Avherever  a  dense,  firm,  fibrous, 
connective  substance  occurs,  as  in  the  cicatricial  gum  corres- 
ponding to  the  <letached  teeth.  This  case,  therefore,  may  be 
termed,  more  appropriately,  cysto-sarcoma  adenoides. 

The  origin  of  the  heterologous,  adenoid  substance  is  quite 
obscure.  It  is  barely  possible  that  it  is  to  be  referred  to  mani- 
fold budding  outgrowths  from  an  enamel  germ.  I  am  unac- 
quainted with  the  record  of  a  similar  case. 

According  to  the  report  of  the  case  by  Podraski,*  the  affection 
commenced  in  a  vigorous  man,  thirty-three  years  of  age,  about 
seven  years  previously,  at  which  time  a  carious  lower  molar  on 
the  left  side  was  extracted  on  account  of  severe  pain.  For 
eighteen  months  afterwards,  there  was  an  absence  of  symptoms. 
After  this  period  had  elapsed,  a  tumor  made  its  appearance  in 
the  gap  left  by  the  extracted  tooth  ;  this  increased,  however, 
quite  slowly,  and  at  the  expiration  of  several  months  had  at- 
tained scarcely  the  size  of  a  hazelnut;  it  then  imparted  a  dis- 
tinct sensation  of  fluctuation  and,  according  to  the  report  of  the 
surgeon  who  was  consulted  at  that  time,  presented  the  appear- 
ance of  a  cyst,  which  was  opened  by  an  incision  and  a  puriform, 
thin  fluid  was  evacuated.  Seven  months  later  the  cyst  was  filled 
again  Avith  a  dense  mass  of  a  pale-red  color ;  it  gave  rise  to  no 
pain,  but  interfered  with  mastication.  The  tumor  was  partially 
cut  away,  burnt  and  cauterized,  but  to  no  purpose.  It  continued 
to  grow  without  occasioning  any  disturbance  of  the  general  sys- 
tem and,  finally,  attained  to  a  considerable  volume.  Resection 
was  performed  and  cicatrization  ensued  speedily  without  the 
least  disfiguration. 

The  proliferations  of  sarcomatous  masses  take  place  in  all 
directions  and  give  rise  to  resorption  of  the  corresponding  por- 
tions of  the  alveolar  processes,  the  alveoli  and  even  the  dental 
roots ;  the  surface  of  the  root  becomes  roughened  and  studded 
with  delicate  needle-like  points ;  the  teeth  become  displaced, 

*  WittelslioRr's  mcdiz.  "Wochenschrift,  Spitalszeitiuig,  1864. 


SARCOMATA    OF    THE    JAWS. 


345 


loosened  and,  finally,  detached.  When  the  proliferations  assume 
a  direction  towards  the  face  and  the  tongue,  portions  of  the 
compact  bony  walls  undergo  complete  resorption,  leaving  the 
tumor  covered  merely  by  the  distended  maxillary  periosteum. 

In  order  to  obtain  a  definite  idea  respecting  the  extent  and 
the  details  of  the  resorption,  and  the  condition  of  the  teeth,  it 


Fig.  98.= 


is  best  to  examine  the  resected  jaw,  after  it  has  been  stripped 
of  the  soft  parts.  Fig.  98  illustrates  a  segment  of  the  jaw,  pre- 
pared in  this  way,  in  which  the  cysto-sarcoma  acquired  about 
the  size  of  an  orange.  The  oral  mucous  membrane  was  very 
tense,  swollen,  and  upon  the  lingual  surface  presented  an  open- 
ing from  which  oozed  a  stringy  fluid.  In  the  substance  of  the 
jaw  lay  a  larger  cyst,  filled  with  fetid,  decomposed  pus,  and  a 
smaller  one  filled  with  a  serous  fluid  which  was  tinged  Avith 
blood.  The  greater  portion  of  the  alveolar  process,  the  lingual 
and  facial  walls  were  wanting,  the  result  of  the  destruction  of  the 
bone  by  the  sarcomatous  new-formation. 

Upon  resected,  macerated  jaws  where  the  newly-formed  mass 
has  not  effected  a  marked  destruction  of  the  bone,  the  compact 
bony  walls,  which  are  involved  in  the  resorption,  present  a  dis- 


*  Fig.  98  shows  a  resected,  inferior  maxillary  arch  from  the  left  side,  from 
which  the  soft  parts  have  been  removed.  (From  the  clinic  of  Prof.  Pilha.) 
View  from  the  facial  side.  As  the  cysto-sarcoma  did  not  involve  the 
inferior,  compact  portion  of  the  maxillary  arch,  the  bone  at  this  part 
was  sawn  horizontally,  and  obliquely  upwards.  The  wisdom  tooth  (a), 
still  inclosed  within  the  dental  sac  and  inclined  towards  the  median  line  of 
the  jaw  and  somewhat  anteriorly,  was  the  only  tooth  remaining.  Natural 
size. 


346  NEW-FORMATIONS. 

tended  appearance  and,  upon  their  internal  surfaces  correspond- 
ing with  the  cavity,  are  beset  with  delicate,  projecting  lamin?e 
of  bone  which  assume  a  fan-shaped  arrangement  where  the  teeth 
are  still  present. 

The  cvsto-sarcomata  are  developed  slowly  and,  frequently, 
exist  for  many  years  without  giving  rise  to  any  painful  sensa- 
tions ;  at  last  resection  is  demanded  by  the  patients  on  account 
of  the  marked  disfigurement  of  the  face  and  the  interference 
with  the  act  of  mastication  which  they  occasion.  They  occur 
chiefly  with  young  persons. 

There  is  a  special  occurrence  to  be  observed  in  these  cases 
which  has  never  been  duly  appreciated  and  is  deserving  of 
thorough  investigation,  namely,  a  retarded  eruption  of  the  wis- 
dom tooth  in  consequence  of  its  oblique  position  (forward  or  in- 
ternal inclination),  or  a  permanent  retention  of  a  tooth  within 
the  jaw,  on  account  of  its  obliquity.  It  is  conceivable  that, 
under  special  circumstances,  the  growing  roots  may  occasion  a 
continued  irritation  of  the  inferior  maxillary  nerves  and  vessels, 
which  gives  rise  to  the  pathological  new-formation. 

Sarcomatous  proliferations  may  manifest  themselves  even 
while  the  development  of  the  tooth  within  the  dental  sac  is  in 
progress.  E.  Neumann*  reports  a  case  of  a  tumor  of  the  lower 
jaw  which  occurred  in  connection  with  a  degeneration  of  the 
connective  tissue  of  a  tooth-sac.  A  spherical  mass,  as  large  as 
an  apple,  occupied  the  interior  of  the  maxillary  bone.  This 
mass  contained,  besides  a  cyst  and  numerous  concrements,  a 
soft,  red,  spongy  tissue,  principally,  and  was  invested  by  a 
capsule  of  connective  tissue  ;  it  consisted  of  papillary,  dendritic 
excrescences  supplied  with  wide  capillary  loops  which  Neumann 
considered  to  be  derived  from  the  normal  papillie  that  project 
from  the  walls  of  the  dental  sac  into  the  gelatinous  tissue  of  the 
enamel  organ.  The  two,  somewhat  stunted,  roots  of  a  molar 
tooth  were  firmly  mortised  into  the  capsule,  while  the  crown, 
having  four  cusps  and  imperfectly  covered  with  enamel,  pro- 
jected into  the  cyst.  The  tooth  was  located  upon  the  lower 
portion  of  the  bony  wall  facing  the  oral  cavity,  directly  beneath 

*  Larigeiibcck's  Archiv.  fiir  Cbinirgio,  Ed.  IX. 


SARCOMATA    OF    THE    JAWS.  347 

the  anterior  bicuspifl.  Its  roots,  directed  downwards,  rested 
upon  the  floor  of  the  bony  sliell,  its  crown  ■was  directed  up- 
Avards.  In  this  case,  then,  we  find,  in  connection  with  a  reten- 
tion-cyst of  a  molar,  a  spongy  new-growth  which,  possibly,  had 
its  origin  in  the  commencement  of  the  growth  of  the  roots  of  a 
very  deeply  located  tooth,  whereby  the  vascular  and  nervous 
trunks  were  subjected  to  an  irritation. 

The  s\mi)\e  periosteal  sarcomata  are  located  upon  the  surface 
of  the  jaw,  but  spread  into  the  substance  of  the  bone,  especially 
if  they  are  of  long  duration.  They  are  composed  of  multifari- 
ously interlacing  bundles  of  elongated,  fusiform  cells.  Myeloid 
sarcomata^  also,  are  recognized,  which  grow  out  from  the  medul- 
lary portion  of  the  jaw  and  inclose,  together  with  others,  the 
multi-nucleated,  gigantic  cells  which  have  been  mentioned  before 
(comp.  p.  325). 

The  osteo- sarcomata,  regarded  by  Virchow  as  that  variety  of 
sarcoma  which  is  more  nearly  allied  to  the  osteomata,  have  their 
representatives  in  the  ossifying  ejjulides  and,  likewise,  occur  upon 
the  jaw  without  the  alveolar  process,  Schuh*  introduces,  under 
the  head  of  secondary  osteoids,  a  variety  as  having  originated 
from  cellular-tissue  tumors,  which  require  notice  in  this  connec- 
tion. According  to  his  observations,  soft,  painless  tumors,  uni- 
form to  the  touch  and  of  remarkably  slow  growth,  exist  for 
several  years,  prior  to  the  occurrence  of  ossification,  in  healthy 
individuals  (in  one  case  in  a  man  with  tuberculosis),  at  the 
middle  period  of  life;  after  ossification  of  the  greater  portion 
has  ensued,  proliferations  of  new,  roundish  lobules  of  connective 
tissue  sometimes  take  place  in  connection  with  an  increased 
formative  action.  They  arise,  generally,  upon  the  outer  sur- 
face of  the  lower  jaw;  sometimes  they  acquire  such  enormous 
dimensions  that  the  tooth  becomes  displaced,  loosened  and  de- 
tached, and  the  mass,  rendered  indistinctly  lobulated  and 
botryoidal  by  the  ossified  portions,  extends  from  the  chin  to  the 
articulation  of  the  lower  jaw,  or  from  the  nose  to  the  mastoid 
process,  and  from  the  zygoma  beyond  the  inferior  margin  of 
the  body  of  the  maxillary  bone. 

*  Pseudoplasmen. 


348  NEW -FORMATIONS. 

Gelatinous  Tumors  (Rokitansky),  Myxomata  (Vlrchow). — 
These  are  developed  -within  the  jaws,  may  acquire  notable 
dimensions  and  are  characterized,  chiefly,  by  a  predominance  of 
young  connective-tissue  cells  in  an  areolar  stroma.  The  mixed 
varieties,  myxoma  fibrosum,  enchondromatosum  and  cystoides 
have  been  observed.  The  following  history  of  a  remarkable 
example  of  the  last  variety  is  given  in  detail  in  consequence  of 
its  infrequent  occurrence  and  its  malignant  character. 

An  extensive  tumor  was  developed  with  great  rapidity  in  the 
lower  jaw,  upon  the  left  side,  and  was  accompanied  by  very 
severe  pain.  Resection  was  performed  by  Dr.  Lewinsky,  and 
the  wound  healed  per  jjrimmn  intenfionem. 

The  neoplasm,  consisting  of  several  protuberances  united 
together,  commencing  just  beneath  the  condyloid  process  on  the 
left  side,  extended  as  far  as  the  canine  tooth  on  the  same  side, 
having  a  long  diameter  of  nearly  one  decimetre.  Only  a  very 
small  portion  of  the  compact  cortical  substance  of  the  bone  re- 
mained, from  the  covulyloid  process  downwards  and  upon  the 
left  of  the  canine  tooth.  The  thickened  periosteum  of  the  cor- 
responding portions  passed  immediately  into  the  dense,  mem- 
branous investment  of  the  tumor.  At  the  angle  of  the  jaw, 
several  protuberances,  as  large  as  a  chestnut,  projected  doAvn- 
wards  and  inwards  and,  having  a  very  much  softened  bony 
covering,  afforded  an  indistinct  sense  of  fluctuation.  The  hori- 
zontal and  ascending  rami  of  the  jaw  were  movable  towards 
each  other.  The  coronoid  process  was  entirely  concealed  by 
the  tumor  which  ascended  from  the  knobbed  inferior  margin  of 
the  jaw  to  a  height  of  seven  to  eight  centimetres.  Two  of  the 
protuberances,  about  the  size  of  a  walnut,  had  ruptured  inter- 
nally and  presented  in  their  interior,  a  gelatinous,  viscid  fluid 
which  was  tinged  with  blood.  These  cavities  were  lined  with  a 
framework  of  minute,  intercommunicating  cysts  and  numerous, 
smooth,  reddish,  soft  excrescences. 

The  oral  mucous  membrane  was  considerably  swollen.  The 
crown  of  an  upward-displaced  molar  tooth  projected  between 
the  swollen  gums. 

The  muscles  attached  to  the  ramus  of  the  jaw  appeared  as  if 
they  had  been  permeated  by  a  gelatinous  (sulzig),  reddish  sub- 


CARCINOMATA    OF    THE    JAWS.  349 

stance;  the  mj^lo-hyoid  nerve  presented  a  fusiform  swelling  in 
its  course,  from  an  infiltration  of  a  similar  substance. 

A  section  through  the  entire  tumor,  from  the  middle  of  the 
condyloid  process  as  far  as  the  sawed  surface,  shoAved  the  bone 
to  have  been  displaced  by  a  gray-reddish  mass,  in  the  process 
of  degeneration  here  and  there,  and  inclosing  cavities  the  size 
of  a  lentil  or  pea.  The  osseous  substance,  with  the  exception 
of  very  slight  portions,  had  disappeared.  The  histological  ap- 
pearances are  illustrated  in  the  Atlas,  Fig.  141. 

It  may  be  remarked,  further,  that  the  muscular  fasciculi  in- 
serted into  the  ramus  of  the  jaw,  their  tendinous  expansions,  the 
gum  and  the  dental  periosteum,  but  not  the  pulp  of  the  molar 
tooth,  were  affected  in  a  similar  manner  by  the  proliferation, 
with  the  exception  that  the  small  cysts  (resembling  those  of  the 
thyroid  gland),  together  with  their  hyaline  contents,  appeared 
to  be  less  abundant  and  in  their  stead  merely  agglomerations  of 
nuclei  Avere  formed,  for  the  most  part.  So  the  primitive  fas- 
ciculi of  the  masseter  muscle,  where  they  were  inserted  into  the 
tendinous  expansion,  presented,  here  and  there,  proliferations 
of  oval  nuclei,  surrounded  by  layers  of  protoplasm,  upon  the  in- 
terior of  the  sarcolemma  whence  the  swollen  bundles  no  longer 
displayed  any  transverse  striation.  At  other  points,  the  pro- 
liferation occurred  between  tendinous  bundles,  nerves  and  blood- 
vessels. 

The  malignant  character  of  this  new- formation  (cysto-myxoma) 
is  indicated  by  the  multifarious  prolongations  into  the  neighbor- 
ing organs,  the  painfulness  and  the  rapid  growth.  The  results 
of  its  histological  examination,  however,  exclude  the  idea  of 
a  cancerous  nature. 

Carcinomata. — EftitJielial  cancer  in  the  oral  cavity,  for  the 
most  part,  takes  its  origin  in  the  gums  of  the  upper  molar  teeth, 
or  in  the  mucous  membrane  of  the  palate.  The  infiltration 
spreads  to  the  dental  periosteum  of  the  corresponding  tooth,  as 
has  been  mentioned  before,  but  does  not  extend  to  the  pulp. 
The  cancer  finally  spreads  anteriorly  in  the  body  of  the  upper 
jaw,  and  the  lymphatic  glands,  usually,  are  attacked  at  a  very 
early  period. 

Epithelial  cancer  of  the  borders  of  the  maxillary  bones  is  dis- 


850  NEW -FORMATIONS. 

tinguished  from  other  varieties,  according  to  C.  0.  Weber,*  by 
its  decided  non-malignant  character,  and  is  curable  by  the  re- 
moval of  all  the  diseased  portion. 

Medullary  cancer  has  its  seat  more  frequently  in  the  upper 
jaw.  According  to  the  observations  of  Schuh,  it  originates  with 
elderly  people  most  frequently  in  the  anterior  wall  of  the  upper 
jaw,  in  the  region  of  the  canine  fossa  and  the  infraorbital  fora- 
men. It  forms,  at  first,  an  immovable,  painless,  firm  tumor 
and,  sometimes,  takes  on  a  rapid  growth  and  spreads  to  the  neigh- 
boring bony  tissue  in  two  to  three  months.  If  it  extends  down- 
wards, towards  the  alveolar  process,  the  teeth  become  loosened 
and  fall  out,  in  which  cases  I  have,  likewise,  found  an  infiltration 
of  the  dental  periosteum,  but  could  never  detect  a  similar  con- 
dition of  the  pulps. 

Schuhf  met  with  other  cases  of  medullary  cancer  where  the 
affection  first  made  its  appearance  upon  the  alveolar  process  op- 
posite the  molar  teeth,  and,  in  one  case,  upon  both  sides  simul- 
taneously. The  teeth  became  detached  while  the  tumor  was 
yet  of  small  size  and  the  covering  of  mucous  membrane  was 
quite  unaffected.  It  was  distinguished  from  parulis  and  necrosis 
by  the  absence  of  pain  and  by  the  non-occurrence  of  exfolia- 
tion of  the  hard,  bony  portion,  and,  moreover,  the  offensive  odor 
emitted  from  the  sockets  of  the  teeth,  the  simultaneous  affection 
of  both  sides  in  one  case  and  the  marked  cachectic  appearance, 
indicated  a  malignant  formation.  The  occurrence  of  the  latter 
symptoms  was  succeeded  by  death,  in  consequence  of  the  con- 
current affection  of  the  internal  organs,  while  the  tumor  of  the 
jaw  had  not  acquired  notable  dimensions. 

Medullary  cancer  may  be  confounded  with  epulis,  and  the 
surest  means  of  discrimination  is  afforded  by  a  microscopical 
examination  of  an  excised  portion. 

Grohe];  describes  a  melanotic^  cancer  of  the  intermaxillary 
bone,  which  originated  in  the  dental  sacs  of  the  incisors  of  a 
boy  live  years  of  age.  All  the  incisor  teeth  were  wanting,  with 
the  exception  of  the  left  lateral,  and  the  eruption  of  that  was 
only  imperfectly  effected.     Grohe  regards  the  dental  sacs  of  the 

*  Op.  cit.  f   Pseudoplasmcn.  X  Yirchow's  Arcliiv,  Bd.  29. 


ANTKUM.  351 

permanent  incisors  as  the  starting-point  of  the  tumor  and  states, 
as  his  opinion,  that  the  development  of  the  former  began  at  a 
very  early  period  and  Avas  arrested  prior  to  the  formation  of 
the  dental  capsules.  The  dental  sac  of  the  lateral  permanent 
incisor  on  the  left  side  was  found,  but  it  contained  no  trace  of 
the  dental  tissues;  it  was  located  directly  behind  the  milk  tooth. 
In  the  place  of  the  lateral  permanent  incisor  on  the  right  side, 
a  bean-sized,  melanotic  mass  was  found,  which  was  united  an- 
teriorly to  the  milk  teeth,  posteriorly  and  upon  either  side,  to 
the  compact  bony  tissue;  no  remains  of  the  permanent  tooth 
were  discovered.  Finally,  the  localities  of  the  two  central  per- 
manent incisors,  no  trace  of  which  was  found,  were  occupied 
by  the  very  large  new-formed  mass.  C.  0.  Weber*  recorded 
four  cases  of  melanotic  cancer  in  this  locality,  and  states  that 
the  affection  often  spreads  from  the  gums  of  the  incisors  to  the 
alveolar  border  and  to  the  body  of  the  jaw. 

Fibrous  cancer,  extending  from  the  gums,  was  not  met  with  by 
Schuh ;  in  the  upper  jaw  it  originated  either  at  a  point  corres- 
ponding to  the  anterior  wall  of  the  antrum,  or  in  the  middle 
portion  at  the  line  of  junction  of  the  alveolar  processes.  On 
the  lower  jaw  it  usually  has  its  origin  in  the  interior  of  the  bony 
tissue;  at  first  it  is  tolerably  circumscribed  and  is  likely  to  be 
confounded  with  fibroma  or  epulis.  Frequently,  the  pain  attend- 
ing it  is  very  slight,  indeed  may  be  wanting  entirely,  even  under 
pressure,  whereby  its  resemblance  to  epulis  is  all  the  more 
marked;  but  the  glands  become  swollen  from  infiltration  at  a 
very  early  period,  and  the  patient  always  has  a  cachectic  appear- 
ance. The  combination  of  the  fibrous  and  medullary  forms  is 
not  an  uncommon  occurrence. 

Gelatinous  cancer,  especially  in  the  form  of  cystoid-gelatinous 
tumors  of  the  upper  jaw,  observed  by  Rokitansky,  and  osteo- 
carcinomata,  with  a  new-form'ation  of  a  radiating  or  alveolated 
bony  tissue  or  of  a  compact  bony  shell  inclosing  the  soft,  can- 
cerous mass,  are  of  very  rare  occurrence. 

Antrum. — Cysts  of  the  antrum  are  met  with,  frequently,  and 
are  of  special  interest  to  the  dentist  in  a  clinical  point  of  view, 

*  Op,  cit. 


352  NEW-FORMATIONS. 

Avben  they  are  developed  upon  the  floor  of  tlie  cavity,  in  the 
mucous  membrane  which,  together  with  the  subjacent  periosteal 
layer,  is  in  immediate  relation  with  the  roots  of  one  or  another 
molar  or  of  the  second  bicuspid.  They  are  liable  to  give  rise  to 
a  fistula  of  the  antrum  when  they  are  accompanied  by  an  inflam- 
mation of  the  dental  periosteum  of  the  corresponding  teeth,  which 
necessitates  a  removal  of  the  latter. 

Luschka*  made  a  special  study  of  these  cysts  and  found 
that,  in  some  cases,  they  occur  singly,  and  in  others,  a  number 
are  developed,  some  of  which  present  broad,  basal  attachments, 
and  others  project  into  the  cavity,  pushing  the  mucous  mem- 
brane before  them,  and  appear  to  be  pediculated.  The  smaller 
cysts,  usually,  contain  a  quite  consistent  mass  resembling  boiled 
sago;  these  masses,  varying  in  size  up  to  that  of  a  hazelnut, 
inclose  a  yellowish,  caseous  matter,  besides  a  light-colored  fluid. 
Frequently,  also,  he  found  the  contents  resembling  inspissated 
mucus,  in  which  cases  the  cysts  presented  a  generally  clouded 
appearance. 

From  his  observations,  Luschka  is  inclined  to  the  opinion 
that  by  far  the  greater  number  of  the  cysts  of  the  antrum  have 
their  origin  in  a  glandular  degeneration,  since  in  very  many  of 
the  branching  utricular  mucous  glands  in  adults,  he  met  with 
cyst-like  expansions,  here  and  there,  both  of  the  principal  tubes 
and  ultimate  follicles. 

In  about  sixty  examinations,  post  mortem,  Luschka  met  with 
the  so-called  pohjpi  of  the  mucous  membrane  in  the  antrum  in 
five  cases  at  least.  According  to  him,  these  polypi  are  clavate 
or  pyriform,  and  attached  by  means  of  their  narrow  extremi- 
ties. In  other  cases,  they  have  a  flattened,  lobulated  form,  and 
are  attached  by  their  broad  extremities.  Usually,  the  outer 
surfaces  are  smootli  and  seldom,  at  least  to  the  naked  eye,  pre- 
sent an  indented  or  foraminated  appearance.  Those  observed 
by  him  varied  from  one-half  to  two  centimetres  in  length. 

The  favorite  seat  of  the  polypi  of  the  antrum  is  upon  its  in- 
ternal wall,  where  they  may  completely  block  up  the  apertures 
of  communication  with  the  middle  meatus,  and  hence  give  rise 


Virehow's  Archiv,  Bd.  8. 


ANTRUM.  353 

to  accumulations  of  mucus.  In  most  cases,  only  a  single  poly- 
pus was  found.  In  one  case,  he  found  six,  which,  together  with 
a  number  of  cysts  and  an  abundance  of  tough  mucus,  entirely 
filled  the  cavity.  The  parenchyma  of  the  polypi  appeared  to 
him  to  be  a  lax,  vascularized,  connective  tissue,  containing  an 
abundance  of  cell-nuclei.  He  has,  as  yet,  been  unable  to  detect 
glands  of  any  sort  in  them. 

These  polypi  occasion  no  inconvenience  so  long  as  their  size 
does  not  exceed  certain  limits  ;*  if  they  continue  to  increase, 
they  distend  the  walls  of  the  cavity  and  occasion  attenuation 
and  resorption  of  the  latter.  In  still  more  advanced  stages, 
they  give  rise  to  a  feeling  of  distention  and  weight  on  the  cheek 
of  the  corresponding  side;  hemorrhages  occur  from  the  nose, 
and  a  discharge  of  a  thin,  mucilaginous,  later  sanious  and  foul- 
smelling  fluid.  After  the  cavity  is  filled  by  the  polypi,  the 
tumor  increases  in  size  and  the  pain  becomes  more  severe  in 
consequence  of  the  distention.  Most  frequently,  the  nasal  v/all 
of  the  antrum  is  perforated  between  the  second  and  third  tur- 
binated bones,  or  the  polypus  enters  the  nasal  cavity  and  is  de- 
veloped therein,  always,  however,  towards  the  posterior  nares. 
Sometimes  perforation  takes  place  in  the  hard  palate ;  a  third 
location  for  the  same  process  is  the  anterior  wall  of  the  upper 
jaw,  and  a  fourth,  the  orbit,  into  which  the  polypus  presses, 
either  through  its  inferior  wall  or  through  the  spheno-maxillary 
fissure  or  the  nasal  fossa  along  the  pterygo-palatine  canal,  or 
through  the  spheno-palatine  foramen.  The  vision  becomes  af- 
fected in  consequence  of  pressure  upon  the  bulbs  and  the  optic 
nerves.  Finally,  the  polypus  extends  through  the  nasal  cavity 
into  the  posterior  nares  and  the  pharynx. 

Passinoi;  over  other  tumors  in  reo:ard  to  Avhich  it  is  doubtful 
whether  or  not  they  are  growths  which  originate  in  the  antrum 
rather  than  in  other  parts,  it  remains  to  be  noticed  that  entozoa 
are  said  to  have  been  found  in  these  cavities  ;■!"  these  may  possi- 
bly have  been  the  larvae  of  flies. 


*  Adelmann,  Krankhafte  Zustiinde  tier  Oberkieferhohle,  Dorpat,  1844. 
f  Benj.  Bell,  1787,  and  Ludw.  Frank,  1815. 

23 


354  ANOMALIES    OF    THE    SECRETIONS. 


YL   ANOMALIES  OF  THE  SECRETIOXS. 

The  teeth  are  bathed  constantly  with  a  fluid  -which  is  fur- 
nished by  the  salivary  and  mucous  glands  that  empty  into  the 
oral  cavity.  The  secretion  of  the  three  pairs  of  salivary 
glands,  the  parotid,  submaxillary,  and  sublingual,  amounts  to 
about  fifteen  hundred  grammes  in  twenty-four  hours,  according 
to  the  measurements  of  Bidder  and  C.  Schmidt,  of  Dorpat. 

The  saliva  varies  in  character  in  the  different  salivary  glands. 
Hoppe-Seyler''*  describes  the  secretion  of  the  parotid  in  man 
and  animals  as  a  fluid  which  is  always  clear,  limpid,  and  watery, 
without  the  slightest  viscidity,  has  an  alkaline  reaction  and, 
Avhen  boiled  or  exposed  to  the  air  at  the  ordinary  temperature, 
is  rendered  turbid  by  the  precipitation  of  carbonate  of  lime. 
The  inorganic  matter,  according  to  the  results  of  most  analyses, 
amounts  to  scarcely  0.5  per  cent.  The  fluid  secreted  by  the 
submaxillary  glands  is  colorless,  gelatinous,  viscid,  and  thready, 
and  has  a  faint  alkaline  reaction ;  it  throws  down  no  deposit 
when  exposed  to  heat  or  allo'wed  to  stand  in  the  air,  but  effer- 
vesces slightly  on  the  addition  of  acids.  The  saliva  of  the  sub- 
lingual is  still  more  tenacious  and  viscid  than  that  of  the  submax- 
illary glands,  and  also  has  an  alkaline  reaction.  The  name  pti/a- 
line  has  been  given  to  the  mucous  or  albuminoid  matter  which 
has  not  yet  been  sufficiently  investigated.  From  these  results 
obtained  by  Hoppe-Seyler,  it  appears  that  the  secretion  of  the 
submaxillary,  but  more  particularly  that  of  the  sublingual  gland, 
contains  mucin  and  in  this  respect,  then,  resembles  the  secre- 
tion of  the  mucous  glands. 

The  mucous  glands  of  the  oral  cavity,  which  claim  notice  in 
this  connection,  are  the  marginal  glands  of  the  tongue,  namely, 
those  of  constant  occurrence  upon  either  side  of  the  apex  and  at 
the  root,  and  those  occasionally  met  with  at  the  middle ;  further, 
the  large  labial  glands,  the  less  numerous  buccal  glands,  and 
those  of  the  hard  and  soft  palate. 

The  mucus  is  a  viscid,  sometimes  clear  and  colorless,  and  at 

*  Handbuch  der  physiol.  und  path,  chemischea  Analyse,  3.  Aufl.,  1870. 


MIXED    SALIVA.  355 

others,  some^Yhat  turbid  secretion,  and  generally  has  an  alkaline 
reaction. 

Moreover,  there  exudes  from  every  portion  of  the  mucous 
membrane  where  there  are  no  glands,  and  even  from  the  gums, 
a  fluid  containing  the  effete,  flattened,  epithelial  cells,  which  are 
replaced  by  younger  cells.  There  is  a  continual  process  of  decay 
and  repair  in  the  oral  cavity. 

The  mixed  saliva  of  the  mouth  is  a  compound  of  saliva  and 
mucus.  According  to  Hoppe-Seyler,  the  saliva  w'hich  escapes 
from  the  mouth,  Avhen  it  is  kept  open  and  no  attempt  is  made  to 
swallow^  usually,  and  always  after  eating,  has  an  alkaline  reac- 
tion; after  prolonged  fasting,  however,  and  particularly  after 
continued  talking,  it  may  become  acid. 

Sulphocyanide  of  potassium  is  found  in  the  mixed  saliva  and 
is  peculiar  to  the  latter,  having  never  been  detected  in  any 
other  part  of  the  organism.  Hoppe-Seyler  states  that  in  man 
the  mixed  saliva  very  frequently  contains  sulphocyanic  acid, 
while  it  cannot  be  found  in  either  of  the  secretions  which  com- 
pose the  saliva,  and  adds,  this  acid,  therefore,  undoubtedly  is  a 
product  of  decomposition,  and  is  formed  primarily  within  the 
oral  cavity,  since  it  is  not  usually  present  after  eating  and, 
Avith  some  individuals,  is  never  found,  especially  with  those  who 
have  sound  teeth,  though  even  with  such  persons  it  is  frequently 
formed  in  the  saliva,  when  the  latter  is  exposed  to  the  air  at 
the  temperature  of  the  blood.  According  to  these  statements, 
this  acid  has  a  pathological  importance  with  reference  to  the 
teeth.  Schonbein  detected  usually,  but  not  ahvays,  a  nitrous 
acid  salt. 

AVright,  in  his  familiar  monograph,*  laid  the  foundation  of  a 
pathology  of  the  saliva.  The  conclusions  drawn  by  him,  ob- 
viously with  reference  to  the  mixed  saliva  and  requiring  revi- 
sion, certainly,  in  many  respects  and  more  extended  investiga- 
tions, have  a  considerable  degree  of  interest  in  connection  with 
our  present  subject.  He  says,  the  acidity  of  the  saliva  in  dif- 
ferent diseases  is  due  to  the  presence  of  divers  acids.  Lactic 
acid  is  found  in  gout,  rheumatism,  intermittent  fever,  diabetes, 

*  On  the  Physiology  and  Pathology  of  the  Saliva,  1842-44. 


356  ANOMALIES    OF    THE    SECRETIONS. 

gastvo-enteritis;  acetic  acid  with  aphthre,  scrofula,  scorbutus, 
variola,  indigestion,  and  after  the  use  of  acid  wines  ;  hydro- 
chloric acid  in  connection  with  simple  gastric  disturbances  ;  uric 
acid  in  gout,  and  oxalic  acid  Avith  digestive  derangements. 
Alkalinity  of  the  saliva  occurs:  a,  in  consequence  of  the  pres- 
ence of  an  excess  of  soda.  It  is  considered  to  imply,  patho- 
logically, general  or  local  disturbances  of  the  nerves.  The 
local  aflections  of  the  nerves  comprise  chiefly  facial  neuralgia 
and  odontalgia,  dependent  upon  denudation  of  the  pulp  without 
inflammation  of  the  periosteum  of  the  root  and  the  adjacent 
tissues.  The  alkalinity,  frequently,  is  an  important  aid  in  diag- 
nosis, inasmuch  as  the  purely  nervous  facial  pain  is  accompanied 
almost  always,  by  an  alkaline,  and  the  rheumatic  pain  by  an 
acid  saliva;  6,  alkaline  saliva,  in  consequence  of  the  presence 
of  ammonia,  is  of  quite  rare  occurrence,  and  is  met  with  in 
severe  catarrhal  aff'ections,  putrid  fever,  scorbutus,  and  purpura 
hemorrhagica.  A  calciferous  saliva,  containing  carbonate  of 
lime,  gives  rise  to  the  formation  of  tartar,  salivary  calculi,  and 
ranula.  The  latter  condition,  by  no  means  of  rare  occurrence, 
is  accompanied  by  dyspeptic  symptoms. 

According  to  the  statements  of  Kiihne,*  urea  is  the  only  ab- 
normal substance  that  has  been  identifled  with  certainty  in  the 
(pure)  saliva;  this  is  found  in  Bright's  disease  and,  also,  in  the 
secretion  from  the  submaxillary  glands  of  animals,  after  the 
ligature  of  the  ureters.  The  sugar  found  in  the  oral  cavity  of 
persons  aff"ected  with  diabetes,  he  says,  is  never  a  product  of 
true  saliva,  but,  probably,  of  the  bronchial  mucus,  since  it  can- 
not be  detected  except  in  cases  where  the  oral  cavity  is  not 
properly  cleansed  or  after  hard  coughing.  Further  investiga- 
tions, he  adds,  are  necessary  in  order  to  determine  whether  the 
characteristic,  often  very  noticeable  odor,  emitted  from  the 
mouths  of  diabetic  persons,  is  dependent  upon  an  ingredient  of 
the  saliva. 

In  febrile  aff'ections,  as  is  well  known,  the  salivary  secretion 
is  diminished,  the  mouth  is  dry,  and  the  epithelium  accumulates, 
since  it  is  not  removed  by  the  saliva. 

*  Physiolog.  Cheniie,  18G8. 


DEPOSITS    UPON   THE    TEETH.  357 

In  catarrhal  inflammation  of  the  oral  mncous  membrane  and, 
especially,  in  mercurial  salivation,  as  much  as  one  per  cent,  of 
inorganic  salts  has  been  found  in  the  saliva  of  the  oral  cavity. 

The  normall}'-  thin,  slightly  turbid,  pellucid,  odorless  coating 
upon  the  teeth,- is  a  secretion  of  the  gums  mixed  with  the  oral 
saliva,  and  accumulates  particularly  in  the  intervals  between 
the  teeth.  In  the  recent  condition,  this  coating  is  neutral  and, 
exceptionally,  it  is  slightly  acid.  In  man,  at  least,  it  is  the 
frequent  seat  of  living  organisms,  concerning  the  nature  of 
which  there  has  been  much  discussion.* 

When  the  coating  forms  a  pultaceous,  unctuous,  cloudy  mass 
having,  occasionally,  a  feculent  odor,  it  consists,  principally,  of 
a  uniformly  fine-granular  mass  which  formerly  was  considered 
to  be  organic  detritus,  but  at  present  is  regarded  as  so-called  ma- 
trix of  leptothrix  and  sometimes  is  distinguished  as  micrococ- 
cus. The  grains  are  disposed  upon  the  outer  surface  of  the 
exfoliated  epithelial  cells,  but,  in  consequence  of  their  minute- 
ness and  rapid  multiplication,  their  cell-nature  and  division  are 
scarcely  recognizable  with  the  optical  appliances  in  use  at  the 
present  day.     The   epithelial  cell  becomes  masked  by  the  in- 


*  Leeuwenhock,  who  discovered  these  (1695),  describes  them  as  liiu's  of 
varj'ing  length  and  uniform  thickness,  bent  in  some  phices,  straight  in 
others,  and  irregularly  disposed.  He  conjectured  that  these  bodies  were 
animals,  from  the  fact  that  he  had  met  with  them  alive  in  water;  he  could, 
however,  detect  no  movement  in  those  of  the  coating  of  the  teeth.  Biihl- 
mann  (1840)  demonstrated  their  property  of  withstanding  the  action  of 
concentrated  sulphuric  and  nitric  acids  and  caustic  alkalies.  For  some 
time,  in  consequence  of  the  uncertainty  regarding  their  nature,  the^y  were 
termed  Biihlmann's  fibres.  Henle  was  the  first  to  suggest  the  vegetable 
nature  of  these  filaments,  while,  on  the  other  hand,  Ficinus  (184G)  advo- 
cated their  animal  nature,  and  designated  the  animated  organisms  as  denti- 
colffi,  and  connected  them  with  caries  of  the  teeth.  Kobin  (1847)  placed 
them  in  the  family  Leptotriche^e  of  Kiitzing,  and  applied  to  them  the  name 
Leptothrix  buccalis  which  has  generally  been  accepted.  Robin,  conse- 
quently, ranked  leptothrix  with  the  algie,  while,  in  modern  mj'cology,  the}' 
are  classed  with  the  fungi.  Hallier  (18G0)  is  inclined  to  have  leptothrix, 
as  a  generic  term,  banished  from  mycology,  considering  this  fungus  to  be 
merely  a  vegetation  form  of  different  lower  fungi  which  he  denominates 
leptothrix  series.  Hallier  goes  still  further  and  states  that  leptothrix  buc- 
calis is  merely  a  form  of  development  of  the  ordinary  mould  fungus,  peni- 
eillium  srl'aucum. 


358  ANOMALIES    OF    THE    SECRETIONS. 

crease  of  the  granular  formations,  and  to  the  latter,  attach 
themselves,  in  the  course  of  time,  bundles  of  tolerably  long, 
usually  interlacing,  uniformly  thick  filaments;  these  frequently 
are  short,  rod-shaped,  and  commordy  are  designated  by  the 
term  Bacteria.  These  vary  in  length  and  thickness,  usujilly  are 
isolated,  less  frequently  occur  in  chain-like  rows,  and  manifest 
periodical  oscillatory  movements.  Leber  and  Rottenstein*  ob- 
tained a  violet  color  from  the  leptothrix  grains  and  filaments, 
by  treatment  with  iodine  and  acids,  a  reaction  which  ensues 
much  more  readily,  as  I  have  also  convinced  myself,  if  dilute 
hydrochloric  acid  be  employed,  after  the  fungus  has  been 
treated  with  an  aqueous  or  alcoholic  solution  of  iodine;  a  mix- 
ture of  glycerine  and  tincture  of  iodine,  I  have  also  found  to  be 
advantageous.  The  reaction,  as  Leber  and  Rottenstein  have 
shown,  displays  the  transverse  markings  of  the  filaments  in  a 
beautiful  manner.  The  interior  portions  are  colored,  and  the 
septa  of  the  filaments  remain  without  being  colored.  The  same 
reaction  ensues,  as  is  self-evident,  with  the  matrix  and  threads 
of  leptothrix  in  the  coating  of  the  tongue. 

The  extremely  delicate,  coiled  filaments  (Spirillum),  which 
occur  in  fewer  numbers  in  the  coating  upon  the  teeth  and  were 
included  by  Ficinus  in  his  Denticolie,  are  regarded  by  several 
mycologists  as  swarm-spores  of  leptothrix.  The  abundant,  ani- 
mated grains,  according  to  the  opinion  of  Hallier,  are  likewise 
swarm-spores  which  arrange  themselves  in  the  form  of  continuous 
chains.  Now  and  then  a  mycelium  is  met  with  identical  (isomorph) 
wuth  that  found  in  the  fungus  of  aphthne  [Oidium  albicans]. 

Leptothrix  is  found  very  frequently  in  the  oral  mucous  mem- 
brane. Robinf  cites  H.  I.  Bowditch,  who  found  that  out  of 
forty-nine  individuals  taken  from  all  classes  of  the  community, 
not  one  of  whom  exhibited  a  diseased  mouth,  forty-seven  pre- 
sented vegetable  or  animal  parasites  in  the  intervals  between 
the  teeth  or  in  the  localities  corresponding  with  the  junction  of 
the  latter  with  the  gums.  Bowditch  considered  them  to  be 
merely  the  result  of  a  want  of  cleanliness. 


*  XJeber  Caries  der  Ziihne,  1867. 

I  Histoirc  ISaturelle  des  Yegetaux  Parasites,  lSo3,  p   351. 


DEPOSITS    UPON    THE    TEETH.  359 

Individuals  ■with  swollen  gums,  pregnant  women,  or  those 
who  are  afflicted  frequently  with  dyspepsia,  with  inflammation 
of  the  tonsils  and  mucous  membrane  of  the  fauces,  or  with  mer- 
curialismus,  scrofulosis,  scorbutus,  or  who  live  in  a  confined 
atmosphere  and  are  especially  exposed  to  agencies  which  pro- 
duce an  irritation  of  the  gums,  are  very  liable  to  be  afiected 
with  leptothrix,  notwithstanding  an  abundant  secretion,  and 
even  with  the  utmost  cleanliness. 

The  colored,  firmly-adlierent  deposit  on  the  teeth  assumes  a 
decided  green,  gray-green,  gray-brownish,  gray-yellowish,  or 
brown  color.  The  green  deposit  occurs,  not  merely  in  advanced 
age,  but  also  upon  the  teeth  of  young  persons,  both  upon  nor- 
mally-formed and  abnormal  teeth,  whether  they  present  accu- 
mulations of  tartar  or  not,  and  whether  they  are  affected  with, 
or  do  not  show  the  least  evidence  of  caries. 

It  is  most  conspicuous  upon  the  labial  surfaces  of  the  front 
teeth  of  the  upper  jaw,  in  the  form  of  a  superficial  discoloration 
of  the  enamel,  which  follows  the  lunated  margin  of  the  gum 
and  acquires  its  greatest  intensity  at  a  certain  distance  from  the 
gingival  margin  and  towards  the  incisive  edges,  coronal  eminences 
and  cusps  of  the  teeth.  The  discolored  portions  present  spots 
where  the  tinge  is  more  or  less  intensified.  The  latter,  usually, 
are  more  evident  in  the  depressions  produced  by  erosion  of  the 
teeth. 

The  thin  deposit,  which  is  distributed  without  uniformity, 
cannot  be  washed  off  with  water  nor  wiped  off",  but  must  be 
scraped  away  Avith  a  sharp  knife,  when  the  enamel  will  be  found 
bright  and  intact. 

Examined  with  reflected  light,  the  deposit  is  found  to  be  a 
granular  mass.  It  is  more  advantageous  to  make  use  of  the 
green  deposit,  after  it  has  been  scraped  away,  for  investigation, 
or  still  better,  the  membrane  of  the  enamel  [Nasmyth's]  which 
may  be  detached  by  means  of  dilute  hydrochloric  acid;  by  these 
means,  it  may  readily  be  demonstrated  that  the  deposit  is  a 
green,  green-yellowish,  uniformly  minutely  granular  mass  Avhich 
is  morphologically  identical  with  the  matrix  of  leptothrix. 

If  the  membrane  of  the  enamel  is  preserved  in  glycerine,  the 


360  ANOMALIES    OF    THE    SECRETIONS. 

green  not  unfrequently  disappears  in  a  few  days,  leaving  a  dirty 
yellow,  yellow-brownish  color. 

I  have  never  observed  a  penetration  of  the  green,  granular 
mass  into  the  peripheral  enamel  layer,  though  I  have  met  with 
systems  of  enamel  prisms,  containing  deposits  of  pigment,  which 
have  acquired  a  greenish  color  in  their  cortical  layers,  a  condi- 
tion which  may  be  explained  by  the  penetration  of  the  green 
coloring  matter. 

The  dark-hrown  deposit^  as  it  occurs  w^ith  habitual  smokers,  is 
observed  upon  the  lingual  surfaces  of  the  teeth,  especially  of  the 
upper  molars  ;  almost  ahvays  it  is  very  thin,  may  be  scratched 
oiF,  accumulates,  particularly,  in  the  depressions  of  the  enamel 
and,  ultimately,  forms  a  sooty  covering  over  the  entire  lingual 
surfaces,  from  the  masticating  surfaces  to  the  borders  of  the 
gums  which,  usually,  are  considerably  retracted,  especially  oppo- 
site the  lingual  roots  of  the  upper  molars. 

If  we  examine  the  surfaces  of  transverse  sections  through  the 
necks  of  teeth  presenting  the  sooty  coating  from  the  use  of  to- 
bacco, the  dentinal  layer  nearest  the  deposit  presents  a  grayish 
discoloration,  giving  an  appearance  as  if  the  adjoining  dentine 
had  become  involved  in  the  staining  process,  so  that  it  might  be 
supposed  that  the  coloring  matter  had  penetrated  to  the  dentine. 
This,  however,  is  not  the  fact.  If  a  portion  of  the  sooty  coating 
be  scraped  off,  the  dark  discoloration  of  the  corresponding  por- 
tion of  the  dentine  disappears,  showing  that  it  was  due  to  the 
transparency  of  the  dentine.  This  appearance  becomes  more 
conspicuous  in  a  cross-section  of  a  senile  tooth  with  a  sooty 
coating  and  horny  translucent  dentine. 

If  the  scrapings  of  the  sooty  coating  are  treated  with  dilute 
hydrochloric  acid,  a  few  bubbles  of  gas  wnll  be  set  free  and 
there  is  left  a  dark-brown,  laminated  mass,  consisting  of  amor- 
phous, brittle  plates  with  an  angular  fracture,  and  containing 
neither  matrix  nor  filaments  of  leptothrix. 

A  peculiar  deposit  with  a  metallic  lustre  is  met  with  especially 
upon  the  teeth  of  cattle.  If  scrapings  of  this  are  treated  with 
hydrochloric  acid,  the  morphological  elements  present  very  thin 
lamellse  of  cornified  epithelium  which  has  acquired  a  yellow 
color.     The  metallic  lustre,  therefore,  is  a  phenomenon  of  inter- 


ODONTOLITHUS — TARTAR.  361 

fcrence  occasioned  by  the  superposition  of  the  uncommonly 
thin,  cemented  lamelhTe. 

The  formation  of  the  adherent  deposit  upon  the  teeth  may 
readily  be  explained.  Since  the  gums  are  attached  to  the  dental 
necks  and  the  extremities  of  the  papillae  upon  the  gingival 
borders  project  slightly,  accumulations  of  the  secretion  of  the 
gums  are  the  more  likely  to  take  place  in  these  localities.  This 
secretion  flows  downwards  upon  the  upper  teeth  and  accumulates 
especially  in  the  depressions  and  grooves  of  the  enamel  surface. 
In  consequence  of  the  frequent  occurrence  of  leptothrix  in  the 
oral  cavity  of  man,  this  epiphyte  finds  a  lodgment  in  the  viscid 
coating  containing  effete  epithelium.  The  latter,  in  conjunction 
Avith  the  proliferating  leptothrix,  becomes  saturated  with  the 
constantly  secreted  saliva,  the  calcareous  salts  of  which  are 
precipitated  in  the  minutely-porous  substratum.  In  this  way, 
there  is  formed  a  cemented  mass  which  cannot  be  removed  from 
the  surface  of  the  enamel  except  with  the  aid  of  sharp  instru- 
ments. With  regard  to  the  deposit  upon  the  teeth  of  cattle, 
and  to  the  brown  deposit  produced  by  tobacco-smoking,  it  is 
obvious  that  leptothrix  is  not  required  in  their  formation. 

Several  varieties  of  odontoUthus,  tartar  are  distinguished,  the 
most  common  of  which  are  the  white  porous,  the  gray-brownish, 
dark-brown  with  black  superficial  layers,  now  and  then  like 
ebony,  and  the  dirty  green. 

The  wliite  tartar,  which  occasionally  has  a  tinge  of  gray  or 
yellow  upon  its  outer  surface  and  in  cross-section  presents  a 
chalky  whiteness,  occurs  upon  the  facial  aspect  of  the  dental 
necks  and  in  greatest  abundance  upon  the  bicuspids  and  molars, 
particularly  upon  those  of  the  upper  jaw;  its  exposed,  rounded, 
outer  surface  is  polished  more  or  less  by  friction  with  the  mucous 
membrane.  Its  formation  begins  at  the  border  of  the  gum  and, 
sometimes,  it  acquires  dimensions  suffipient  to  envelop  completely 
the  crowns  and  their  masticating  surfaces.  If  the  roots  of  the 
teeth  are  deprived  of  their  protective  coverings  in  consequence 
of  a  continued  accumulation  of  tartar  and  chronic  suppuration 
of  the  gums,  periosteum  of  the  roots  and  alveoli,  the  tartar  then 
extends  to  the  apices  of  the  roots  and  may  spread  even  beyond 
them.    As  it  is  disposed  about  the  separate  teeth,  and  the  latter 


362  ANOMALIES    OF    TUE    SECRETIONS. 

admit  of  a  certain  degree  of  movement  during  mastication,  it  is 
obvious  that  adjacent  masses  of  tartar  become  smooth  from 
friction  with  each  other.  The  lingual  surfaces  of  tartar  are 
rendered  smooth  by  the  movements  of  the  tongue.  Fig.  128  in 
the  Atlas  illustrates  a  colossal  mass  of  tartar  inclosino;  four 
teeth,  ■which  was  reported  by  Ileider.*  Strasky,  of  Lemberg, 
removed  this  deposit  from  the  mouth  of  a  Polish  Jewess  who 
went  to  Lemberg  for  the  purpose  of  being  operated  upon  for  the 
removal  of  a  supposed  tumor  of  the  bone,  for  which  she  had  been 
treated  at  home,  without  success,  with  iodine  and  mercurial 
preparations. 

The  explanation  of  the  fact  that  tartar  is  formed  in  greater 
abundance  upon  the  facial  surfaces  of  the  upper  bicuspids  and 
molars,  is  to  be  sought  in  the  local  relations,  in  the  fact  that 
Stenon's  duct  empties  directly  opposite  the  second  upper  bicus- 
pid. The  saliva  washes  over  the  above-named  teeth  in  great 
abundance  and  is  rapidly  removed  from  their  lingual  surfaces 
by  the  movements  of  the  tongue,  while  upon  their  facial  surfaces, 
in  consequence  of  the  contact  of  the  cheeks  with  the  teeth,  com- 
paratively less  is  removed. 

Large  accumulations  of  tartar  are  formed  upon  those  teeth 
which  are  deprived  of  their  antagonists,  or  upon  painful  teeth 
which  compel  the  patient  to  abstain  from  using  the  corresponding 
side  in  chewing  and  biting,  and  to  neglect  proper  cleanliness. 
In  either  case,  abrasion  of  the  forming  tartar  is  prevented. 

The  lingual  and  facial  surfaces  of  the  necks  of  the  lower  in- 
cisors, likewise,  are  frequently  the  seat  of  the  yellowish-white, 
porous  tartar.  The  saliva  from  the  submaxillary  and  sublingual 
glands  collects  upon  the  floor  of  the  oral  cavity  and  gives  rise  to 
an  increased  deposit  which  sometimes  spreads  nearly  to  the 
apices  of  the  dental  roots. 

Castle  asserts  that  the  tartar  sometimes  is  deposited  even  in 
the  foramen  which  serves  for  the  transmission  of  the  dental 
nerves,  and  occasions  severe  neuralgias  in  the  branches  of  the 
fifth  pair ;  that  it  is  deposited,  also,  upon  artificial  teeth,  upon 

*  Mittlioiluniren  des  Centralvereines  deutscher  Zahnarzte,  1860. 


ODONTOLITHUS — TARTAR.  363 

tlie  gold  and  silver  or  gutta-percha  in  which  the  artificial  teeth 
are  set,  but  never  within  or  upon  the  alveolar  processes. 

Polished  surfaces  of  sections  of  the  larger  deposits  of  tartar 
display  concentric  laminne  corresponding  in  their  direction  with 
the  curvature  of  the  outer  surfaces.  Thin  slices  are  not  in- 
structive since  they  present  merely  amorphous,  opaque  masses 
which,  for  the  most  part,  afford  a  considerable  amount  of  organic 
residue  when  treated  with  acids.  I  have  succeeded  better  in 
delineating  the  details  of  the  laminations,  by  making  sections  of 
fragments  of  the  tartar  by  means  of  a  sharp  knife  and  treating 
them  Avith  heated  acetic  acid.  When  the  calcareous  salts  have 
been  removed,  coherent  systems  of  mortised,  delicate,  sharply- 
defined  layers,  separated  from  one  another  by  intervals  measuring 
scarcely  0.001  millimetre,  are  brought  into  view.  Roundish 
disks  of  various  diameters  form  the  foci ;  around  the  whole  or 
portions  of  these,  the  layers  are  disposed  as  in  the  agate,  pre- 
senting a  resemblance  to  those  displayed  in  very  thin  sections 
of  urinary  calculi  of  uric  acid.  Here  and  there,  laminated  or 
separate,  effete  epithelial  cells,  and  the  granular  matrix  or 
numerous  filaments  of  leptothrix,  are  met  with.  If  a  number 
of  thin  slices  of  tartar  are  treated  with  very  dilute  hydrochloric 
acid  for  the  purpose  of  studying  the  organic  residuum,  in  ad- 
dition to  occasional  vegetable  remains,  thallus-threads  of  oidium 
are  found,  occasionally,  in  not  inconsiderable  numbers  (Atlas, 
Fig.  129),  forming  free  projections  upon  the  corroded  portions. 

The  gray-hroivn  or  darlc-hrown  tartar  is  considerably  harder 
than  the  preceding,  accumulates  in  smaller  masses  and  more 
slowly  and  attaches  itself  chiefly  to  the  lingual  surfaces  of  the 
necks  of  the  lower  incisors ;  it  occurs  often  upon  the  upper  in- 
cisors, canines,  and  bicuspids,  less  frequently  upon  the  lingual 
surfaces  of  the  molars  and  still  more  rarely  upon  their  buccal 
surfaces. 

Surfaces  of  sections  of  this  form  of  tartar  display  irregularly 
w^avy  laminfe,  presenting  various  shades  of  dirty-brown,  gray 
and  yellow.  The  laminae  vary  in  thickness,  for  the  most  part, 
present  imperceptible  transitions  from  one  into  another  and, 
here  and  there,  form  a  distinctly  stratified  system.  Since,  in 
many  places,  the  dark  and  bright  layers  are  arranged  in  close 


364  ANOMALIES    OF    THE    SECRETIONS. 

proximity,  an  appearance  is  presented,  bearing  a  strong  resem- 
blance to  the  white  porous  tartar  (Ath^s,  Fig.  130). 

Thin  sections  or  slices,  from  which  the  calcareous  salts  have 
been  removed  by  means  of  dilute  hydrochloric  or  heated  acetic 
acid,  do  not  present  any  lamelU^  of  effete  incrusted  epithelium, 
but  contain  an  abundant  homogeneous  mass  of  minutely  granu- 
lar leptothrix.  Quite  numerous  leptothrix  filaments,  likewise, 
occur  in  tufts  here  and  there;  numbers  of  isolated,  so-called 
bacteria,  also,  may  readily  be  demonstrated  by  means  of  tritura- 
tion. The  brown  color,  in  many  layers,  arises  partly  from  dark 
and  light  brown,  free  granules,  and  in  part,  also,  it  is  due  to  the 
general  brownish  tinge  of  the  molecular  mass.  Sometimes,  a 
color  shading  into  greenish  is  met  with. 

The  gray-green  tartar  is  very  hard  and  forms  a  ring  around 
the  neck  of  the  tooth,  generally  several  millimetres  broad;  quite 
often  it  is  covered  by  the  gums  and  has  a  more  or  less  nodulated 
outer  surface;  it  is  thickest  in  the  portion  adjacent  to  the 
gingival  border,  and  becomes  attenuated  both  in  the  direction  of 
the  root  and  towards  the  crown. 

Hydrochloric  acid  slowly  extracts  its  calcareous  salts,  leav- 
ing a  comparatively  large  amount  of  greenish  leptothrix  matrix, 
together  with  numerous  filaments.  Brown,  granular  agglomera- 
tions are  imbedded  here  and  there. 

Tartar  is  very  common  on  the  teeth  of  old  animals.  In  the 
horse,  white  tartar  is  distinguished  by  its  containing  an  un- 
usually large  amount  of  carbonate  of  lime,  Avhich  is  indicated  by 
the  very  active  eff"ervescence  produced  on  the  addition  of  acids. 
In  the  dog,  the  green  tartar  exhibits  a  comparatively  large 
amount  of  organic  matter.  The  tartar  with  a  metallic  lustre, 
which  is  found  on  the  teeth  of  cattle,  is  of  especial  interest,  from 
the  fact  that  in  this  the  mass  of  leptothrix  and  the  necrotic  epi- 
thelial layers  are  sharply  distinguished  from  each  other.  Even 
with  the  naked  eye,  a  number  of  fine  pores  may  be  seen  upon 
the  surface  of  this  form  of  tartar ;  with  the  aid  of  a  lens,  thin, 
decalcified  slices  display  a  network  of  canals  which  prove  to  be 
cavities  filled  with  a  mass  of  leptothrix.  Between  these  cavities 
lie  the  multifarious,  brittle,  yellow  lamellfB  of  cornified  epithe- 
lium. 


ODONTOLITHUS — TARTAR.  365 

Mandl*  has  advanced  the  view  that  tartar  is  composed  of  a 
cluster  of  vibriones  which  are  encased  in  a  coating  of  lime. 
Though  it  is  true  that  parasitic  organisms  participate  in  the 
formation  of  tartar,  nevertheless  the  view  of  Mandl  is  untenable, 
according  to  the  ideas  of  the  present  day,  since  the  supposed 
vibrios  are  constituent  portions  of  leptothrix  and  possess  no  cal- 
careous coats. 

The  amount  of  calcareous  salts,  the  relative  proportion  of 
carbonate  and  phosphate  of  lime,  the  quantity  of  organic  matter, 
the  quantity  of  leptothrix  buccalis  distributed  in  the  calcified 
portions  and  the  occasionally  included  particles  of  food  present 
many  variations  in  the  different  kinds  of  tartar.  Generally 
speaking,  it  is  observed  that  tartar  contains  the  same  constitu- 
ents as  salivary  calculi  with  the  exception  that  it  has  a  greater 
amount  of  phosphate  of  lime  than  the  latter.  Berzelius,  as  is 
well  known,  also  demonstrated  the  existence  of  an  albuminoid 
substance  in  tartar,  called  ptyaline^  a  fact  of  importance  inas- 
much as  the  participation  of  the  saliva  in  the  formation  of  tartar 
is  vindicated  even  upon  chemical  grounds. 

Two  elements  are  to  be  discriminated  in  connection  Avith  the 
formation  of  tartar,  in  the  first  place,  the  organic  cement  and 
in  the  second  place,  the  inorganic  salts.  The  former  is  fur- 
nished by  the  mucus  and  epithelium  from  the  gums,  by  the 
mucin-holding  substance  of  the  mixed  saliva,  and  by  the  lepto- 
thrix buccalis  which  proliferates  in  the  degenerating  substances. 
It  cannot  be  asserted  that  the  latter  is  an  essential  ingredient 
of  tartar ;  it  gives  firmness,  however,  to  the  organic  cement  and 
increases  the  consistence  of  the  green  and  brown  tartar. 

The  calcareous  salts  are  deposited  chiefly  from  the  saliva. 
If  the  latter  contains  an  unusually  large  amount  of  such  salts 
and,  especially,  if  the  salivary  secretion  is  augmented,  the  tartar 
is  deposited  with  comparatively  greater  rapidity.  Hoppe- 
Seyler  asserts  that,  in  cases  of  iodine  and  mercurial  salivation, 
the  saliva  contains  an  abundant  admixture  of  the  secretion  pro- 
duced by  the  catarrhal  inflammation  of  the  mouth  and  throat 
and,  hence,  on  being  boiled  with  the  addition  of  a  little  acid,  it 

*  Comptes  rendus  de  I'Acud.  des  Sciences  de  Paris,  t.  17. 


366  ANOMALIES    OF    THE    SECRETIONS. 

usually  affords  an  abundant  coagulum,  particularly  in  cases  of 
mercurial  salivation;  moreover,  as  has  already  been  observed,  it 
contains  nearly  one  per  cent,  of  inorganic  salts,  while  normal 
saliva  contains  a  much  smaller  amount. 

The  concrement  becomes  foraminated  by  the  constant  action 
of  the  saliva  upon  the  surface  of  the  tartar ;  indentations  and 
fissures  are  formed  (Atlas,  Fig.  128),  which  afford  a  favorable 
nidus  for  the  proliferation  of  leptothrix  buccalis.  These  cir- 
cumstances explain  the  occurrence  of  sharply  defined  channels 
filled  with  a  mass  of  leptothrix,  which  are  so  conspicuous  in  the 
tartar  of  the  teeth  of  cattle. 

Fox*  stated  explicitly  that,  with  the  exception  of  caries,  noth- 
ing is  so  pernicious  to  the  healthy  condition  of  the  mouth  and 
the  durability  of  the  teeth  as  the  accumulation  of  tartar. 
Hunter,  and  previous  to  him,  the  French  dentists  Fauchard  and 
Bourdet,  were  quite  well  aware  of  the  injurious  effects  of  tartar. 
These  comprise  the  production  of  a  catarrhal  inflammation  of 
the  gums,  the  loosening  of  the  adhesion  of  the  latter  to  the 
necks  of  the  teeth  ;  the  tenacious  mucus  collects  in  the  pockets 
formed  by  the  gums  and  forms  an  incrustation  upon  the  necks 
of  the  teeth  and  a  superficial  ulceration  takes  place  upon  the 
borders  of  the  gums.  Not  infrequently  the  irritated  gums  be- 
come swollen  and  superficial  hemorrhages  ensue.  If  the  gum 
is  involved  where  it  becomes  continuous  with  the  root-membrane, 
a  sensitiveness  of  the  tooth  is  produced.  The  accumulated 
purulent  mucus  undergoes  decomposition  and  emits  a  fetid  odor 
from  the  mouth;  it  undermines  the  contiguous  alveolar  wall  in 
which  it  induces  a  resorption;  then  the  tartar  is  deposited 
directly  upon  the  cement  of  the  root,  without  affecting  the  den- 
tal substances  in  the  least,  and  it  is  not  an  uncommon  occur- 
rence for  the  corresponding  root  to  be  incrusted  as  far  as  its 
apex  in  conse(i[uence  of  which,  the  tooth,  especially  if  it  has  but 
a  single  root,  becomes  loosened  and  detached.  Frequently, 
however,  the  sensitiveness  becomes  so  marked  in  consequence 
of  the  affection  of  the  periosteum  of  the  root,  that  patients 
decide  upon  extraction  even  before  the  tooth  has  become  loose. 

*  Nat.  Hist,  of  Human  Teeth,  p.  95. 


CARIES    OF    THE    TEETH.  367 

The  tartar,  therefore,  does  not  injure  the  teeth  directly,  but 
merely  in  an  indirect  manner  through  the  irritation  produced  by 
its  more  or  less  rough,  tuberculated  surface  upon  the  gum, 
chiefly  within  the  pockets  formed  by  the  latter.  If  it  has  sharp 
edges  projecting  over  the  gum,  as  is  wont  to  be  the  case,  par- 
ticularly upon  the  lingual  surfaces  of  the  lower  incisors,  or  if 
one  or  another  portion  of  the  tartar  break  away,  still  further 
injurious  eifects  are  produced.  Large  masses  of  tartar  do  not 
occasion  more  serious  effects,  since  their  outer  surfaces  become 
smooth. 

It  is  impossible  as  yet  to  explain,  in  every  case,  the  deposit 
of  tartar  upon  the  teeth  of  many  persons,  in  spite  of  the  utmost 
cleanliness. 

Calciferous  saliva  and  catarrh  (comp.  inflammations  of  the 
gums)  favor  the  formation  of  tartar,  as  also  does  advanced  age, 
principally  because  at  this  period  the  secretions  are  diminished 
in  quantity  and  the  regeneration  of  the  epithelium  of  the  gums 
takes  place  more  slowly. 

Caries  of  the  Teeth. — It  was  quite  natural  to  transfer  to 
the  teeth  the  signification  implied  in  the  expression  "  caries 
(Beinfrass)  of  bone,"  indeed  the  fundamental  phenomena, 
namely,  the  destruction  of  the  hard  tissues,  offered  a  striking 
analogy.  In  their  development,  however,  the  two  processes  by 
no  means  present  such  an  identity.  Caries  of  the  bone,  as  is 
well  known,  is  an  inflammatory  process  (ostitis)  which  originates 
in  the  soft  parts  of  the  bone  and  erodes  its  hard  tissues.  This 
is  not  the  case  with  the  carious  process  in  the  teeth,  which  com- 
mences in  the  hard  tissues  and  spreads  to  the  vascularized  and 
nervous  dental  pulp.  Upon  close  investigation,  the  latter  pro- 
cess is  found  to  be  so  entirely  distinct  from  the  former  that 
the  attempt  has  repeatedly  been  made  to  expunge  altogether 
from  the  nomenclature  of  diseases  of  the  teeth,  the  expression 
caries  of  the  teeth,  and  Klenke  has  proposed  to  substitute  the 
general  term  "decay  (Verderbniss)  of  the  teeth."  This  propo- 
sition, however,  did  not  meet  Avith  very  general  acceptance,  and 
it  must  be  acknowledged  that,  on  the  one  hand,  nothing  is 
gained  by  the  introduction  of  so  vague  an  expression,  and  on 
the  other  hand,  it  would  be  almost  an  impossibility  to  give  up  a 


368  ANOMALIES    OF    THE    SECRETIONS. 

term  ■wliicli  lias  become  naturalized  in  dentistry  and,  indeed, 
even  with  the  general  public. 

There  is  by  no  means  a  unanimity  of  opinion  in  regard  to 
the  category  of  diseases  under  which  caries  of  the  teeth  is  to  be 
classed.  The  ground  which  we  have  taken  is  indicated  by  the 
fact  that  caries  is  introduced  under  the  head  of  anomalies  of  the 
secretions,  or,  in  other  words,  it  is  considered  to  be  the  result 
of  abnormal  secretion.  The  reasons  for  this  view  will  appear 
in  the  following  pages. 

The  importance  of  the  process  in  this  very  frequent  affection, 
the  treatment  of  which  forms  the  largest  part  of  the  practice  of 
the  dentist,  leads  me  to  enter  minutely  into  the  Idstory  of  caries. 
The  latter,  moreover,  is  instructive,  inasmuch  as  it  indicates 
the  marked  proneness  of  the  human  mind,  from  its  natural  ten- 
dency to  investigate  the  causal  connection  of  phenomena,  to 
wander  in  the  mazes  of  hypotheses,  Avhen,  in  the  absence 
of  sufficient  preliminary  knowledge,  it  is  prevented  from  pene- 
trating the  realms  of  truth.  Notwithstanding  the  fact  that  our 
knoAvledge  is  advancing,  unquestionably,  with  the  continual  addi- 
tions to  the  auxiliary  means  at  our  command  for  carrying  on  the 
Avork,  it  must,  however,  be  acknowledged  that  a  theory  with 
regard  to  caries,  with  a  thoroughly  scientific  basis  in  all  its  de- 
tails, is  still  wanting. 

Hippocrates  and  his  pupils,  as  is  well  known,  were  humoral 
pathologists,  and  hence  they  referred  caries  to  the  bad  condition 
of  the  humors,  a  view  which  was  maintained  by  most  physicians 
for  more  than  a  thousand  years  and,  even  at  the  present  day, 
is  upheld  by  the  traditions  of  the  common  people.  Imperfect 
observation  and,  perhaps,  intentional  deception,  gave  birth  to 
the  worm-hypothesis  which  furnished  a  decidedly  more  concrete 
idea  of  the  genesis  of  caries.  Various  means  were  employed  to 
destroy  the  intruders.  Fauchard  (1728)  took  a  great  deal  of 
pains  in  order  to  discover  the  worms  supposed  to  be  the  most 
common  cause  of  toothaches,  both  in  carious  teeth  and  in  tartar; 
he  never  succeeded  in  finding  any. 

Fauchard  distinguished  several  forms  of  caries:  a  scorbutic, 
variolous,  scrofulous,  a  moist  or  putrid  and  a  dry,  a  superficial, 
of  little  consequence,  and  a  deep  form  which  gave  rise  to  severe 


HISTORY    OF    CARIES    OF    THE    TEETH.  369 

pain.  He  assumed  an  internal  and  an  external  cause  for 
caries,  as  he  did  for  all  diseases  of  the  teeth.  The  former,  he 
states,  acts  upon  the  roots,  both  upon  their  outer  and  inner  sur- 
faces, meaning  by  the  latter,  the  root-canal,  and  also  upon  the 
internal  surface  of  the  dental  cavity  ;  caries,  which  is  induced 
by  internal  causes,  he  continues,  is  recognized  with  considera- 
ble difficulty,  especially  when  the  roots  or  the  necks  of  the 
teeth,  merely,  are  attacked,  since  it  is  concealed  from  view  by  the 
gums  and  the  dental  sockets ;  caries,  depending  upon  external 
causes,  attacks  the  outer  portion  of  the  tooth,  i.e.^  the  enamel, 
sometimes  the  neck,  and  at  others  the  roots  ;  the  internal  causes 
are  referable,  generally,  to  the  quantity  or  quality  of  faulty, 
acrid  or  corrosive  lymph. 

Bourdet*  maintained  similar  views  with  Fauchard,  and  states 
that,  when  the  fluids  contained  in  dental  vessels  are  too  thick, 
they  coagulate,  putrefy,  since  they  are  confined,  and  act  directly 
upon  the  tooth.  He  explains  why  it  is  that,  when  a  tooth  decays, 
the  corresponding  tooth  on  the  opposite  side  almost  always  is 
similarly  and  symmetrically  affected  shortly  afterwards.  Since 
corresponding  teeth,  he  says,  commonly  ossify  simultaneously, 
and  pursue  the  same  order  of  development,  so  the  common  mor- 
bid process  manifests  itself  in  the  corresponding  teeth  ;  the  large 
molars,  therefore,  succumb  earlier  to  caries,  if  they  are  attacked 
during  their  ossification.  He  evidently  alludes  here  to  the  ero- 
sion of  the  teeth  (comp.  p.  143). 

Hunter  started  with  false  physiological  views;  he  regarded 
the  teeth  as  foreign  substances,  in  a  certain  degree,  since  they  re- 
ceive nourishment  only  while  sound  and  fit  for  service  and,  when 
they  are  diseased,  they  do  not  receive  the  common  benefits  re- 
ceived by  other  parts  which  they  resemble  and  Avith  which  they 
stand  in  a  certain  connection.  He  was  inclined  to  regard  caries 
as  a  sort  of  cold  gangrene  or  mortification,  but  he  states,  fur- 
ther, that  during  life  there  is  some  operation  going  on  in  the 
tooth  which  produces  a  change  in  the  diseased  part.  If  a  por- 
tion of  the  tooth  is  dead,  he  says,  the  remaining  living  portion 
has  not  the  power  of  throwing  it  off  and  forming  an  external 

*  De  I'art  du  Denliste,  t.  i,  1757. 
24 


370  ANOMALIES    OF    THE    SECKETIONS. 

surface  capable  of  supporting  itself  like  the  rest  of  the  bof]3% 
The  caries,  sometimes,  though  rarely,  begins  on  the  inside  of 
the  tooth,  and  in  this  case,  the  latter  acquires  a  shining  black- 
ness from  the  dark  color  being  seen  through  the  remaining  ex- 
ternal shell  of  the  tooth,  and  no  opening  is  found  leading  to  the 
pulp- cavity. 

Fox*  considered  the  proximate  cause  of  dental  caries  to  be 
"an  inflammation  in  the  bone  of  the  crown  of  the  tooth,  which, 
on  account  of  its  peculiar  structure,  terminates  in  mortification." 

The  dental  pulp,  he  says,  becomes  the  subject  of  inflammation, 
and  induces  caries  ;  he  draws  a  parallel  between  pulp-membrane 
and  periosteum  of  bone  and,  evidently,  confounds  necrosis  Avith 
caries. 

Thomas  Bellf  lays  stress  upon  the  erroneous  application  of 
the  term  caries  in  connection  with  the  teeth,  which,  he  says,  is 
not  in  the  least  analogous  to  true  caries  of  bone,  and  proposes 
the  term  gangrene  (Brand)  for  the  teeth  ;  this  he  defines  as 
mortification  of  some  portion  of  the  tooth,  which  occasions  a  pro- 
gressive destruction  of  the  dental  substance.  He  corrects  the 
erroneous  ideas  entertained  by  Fox,  but  agrees  with  him  in  believ- 
in<i-  that  inflammation  is  the  cause  of  caries,  that  the  hard  dental 
tissues  give  way  to  the  inflammatory  process  in  the  manner  of 
bone,  that  the  symptoms  in  either  case  are  identical  and  that, 
now  and  then,  the  tooth  presents  spots  which  are  injected  with 
the  red  constituents  of  the  blood.  Bell  probably  means  by  this 
the  portions  of  dentine  which  are  imbued  with  the  coloring 
matter  of  the  blood,  the  reddened  teeth.  With  reference  to 
the  occurrence  of  caries  which  proceeds  from  without  internally, 
he  considers  that  those  portions  most  removed  from  the  nutrient 
vessels  and  nerves  are  least  capable  of  resisting  decay,  as  we 
know  is  the  case  in  other  parts  of  the  organism.  He  denies 
that  the  destruction  which  occurs  in  artificial  teeth  is  analogous 
to  caries,  and  maintains  the  falsity  of  the  view  that  caries  is  due 
to  external  causes  which  act  upon  the  enamel.  In  him,  there- 
fore, we  find  an  advocate  of  the  pure  vital  theory  of  dental  caries. 


*  Op.  cit.,  p.  12. 

t  Anat.  Phys.  and  Path,  of  tlie  Teeth,  18o-5,  p.  120., 


HISTORY    OF    CARIES    OF    THE    TEETH.  371 

Desirabode*  states  that  the  different  views  in  regard  to  the 
nature  of  caries  arose  from  the  fact  that  all  the  various  patho- 
logical changes  upon  the  crowns  of  teeth  have  been  included 
under  this  name ;  that  the  degenerations  to  which  the  term 
caries  is  applied  are  occasioned  in  part  by  local  agencies,  and 
consist  in  a  chemical  destruction  of  the  dental  tissues,  which 
process  takes  place  in  a  direction  from  without  inwards  ;  in  other 
cases,  they  arise  from  some  injury  to  the  pulp  or  from  a  congeni- 
tal defect  in  the  dentine,  and  are  developed  spontaneously  from 
Avithin  outwards.  The  term  caries,  he  adds,  is  more  applicable 
to  the  latter  variety  than  to  the  former. 

Regnardf  upholds  the  pure  chemical  theory  with  reference  to 
dental  caries,  considering  it  to  be  merely  a  destruction  by  acids 
Avhich  are  formeil  within  the  mouth.  He  adds,  silk  lio-atures 
wound  around  the  teeth  occasion  the  destruction  of  the  enamel ; 
caps  applied  over  the  teeth,  whether  of  wax  or  of  some  metallic 
substance,  promote  their  destruction ;  human  teeth,  artificial 
sets  and  separate  teeth,  made  of  the  ivory  from  the  tusk  of  the 
hippopotamus,  undergo  destruction. 

Linderer|  gives  a  correct  description  of  the  carious  process 
in  enamel  and  dentine,  and  directs  attention  to  the  light  dentinal 
tissue  surrounding  the  carious  portion.  Inflammation  in  den- 
tine, he  says,  is  not  conceivable,  sinCe  it  contains  no  bloodves- 
sels. According  to  his  view,  caries  is  a  chemical  destruction  of 
the  teeth,  induced  by  the  oral  fluids.  He  distinguishes  three 
stages ;  in  the  first,  the  enamel  is  destroyed  and  the  lime  of  the 
dentine  is  set  free  ;  in  the  second,  the  discoloration  of  the  pre- 
viously affected  tissue  becomes  manifest,  and  in  the  third,  the 
diseased  mass  liquefies,  and  a  cavity  is  formed  in  the  tooth.  He 
denies  the  occurrence  of  the  so-called  internal  caries,  and  admits 
that  of  an  inherited  caries  only  in  the  sense  that  the  disposition 
is  inherited. 

FicinusS   thinks  he  has  discovered  the  soil  in   which   caries 


*  Elements  de  I'art  du  Dentiste  (184G),  t.  i,  p.  220. 
f  Gazette  des  Hopitaux,  1838. 
J  Zabnheilkunde. 

I  Journal  fur  Chirurgie  und  Augenheilkunde  von  "Waltlier  und  Amnion, 
1846. 


372  ANOMALIES    OF    THE    SECRETIONS. 

germinates  in  the  "cuticle  of  the  enamel;"  the  brownish, 
sometimes  black  deposit  upon  the  teeth,  he  says,  is  occasioned 
by  the  superficial  decomposition  of  the  membrane  which  covers 
the  enamel ;  this  decomposition  either  is  consequent  upon,  or 
has,  as  its  sequel,  a  putrefactive  process  which,  in  part,  is  caused 
by  the  presence  of  myriads  of  infusoria  in  the  teeth  (his  Denti- 
colie,  which,  he  admits,  become  Biihlmann's  fibres  by  conjuga- 
tion), and  in  part  is  developed  from  the  first  in  the  ordinary 
manner  and  occasions  a  gradual  exfoliation  of  the  membrane. 
The  putrefaction  thus  induced,  he  continues,  spreads  to  the 
enamel-cells,  where  its  progress  is  slow,  extracts  their  inorganic 
portions,  ruptures  their  mutual  connections  and,  finally,  reaches 
the  tubular  dentinal  tissue,  into  which  it  extends  in  a  similar 
manner,  but  with  greater  rapidity,  and  terminates  only  with 
the  destruction  of  the  entire  tooth.  He  opposes  the  view  of 
Erdl  who,  from  the  external  similarity  of  the  deposit  on  the 
teeth  to  Protocoecus,  assumes  the  presence  of  a  parasitic  cryp- 
togam which,  however,  cannot  germinate  except  upon  a  dental 
surface  that  has  undergone  a  pathological  change. 

Klenke*  opposes  the  assertion  that  caries,  in  every  instance, 
in  due  to  destructive  oral  fluids,  and  advocates  the  occurrence 
of  a  central  or  inflammatory  dental  caries.  There  is  a  second 
form,  he  says,  in  which  the  dental  tissues  are  destroyed  by  a 
phy  to- parasite  which  he  calls  Protococcus  den  talis.  A  third 
form,  the  putrid,  consists  in  a  true  putrefactive  process,  whereby, 
with  the  co-operation  of  infusoria,  the  dental  tissues  are  decora- 
posed.  _  In  this  he  agrees  with  the  views  elaborated  by  Ficinus. 
In  a  fourth  form,  which  he  distinguishes  as  dissolutio  cliemica  s. 
chronica,  a  disintegration  of  the  dental  tissues  is  occasioned  by 
purely  chemical  means  on  the  part  of  the  oral  fluids,  and  by  a 
disposition  inherent  in  the  chemical  combination  of  the  dental 
tissues. 

Tomesf  has  extended  our  knowledge  with  regard  to  the  path- 
ological changes  presented  by  the  cartilaginous  softened  carious 
dentine;    he  asserts  that,  in  cross-sections,  the  tubules  of  the 

*  Die  Verderbniss  der  Zahnc,  1850. 
f  Sj-stem  of  Dental  Surgery. 


HISTORY    OF    CARIES    OF    TUE    TEETH.  373 

latter  are  surrounded  by  a  very  thick  sheath,  the  outline  of  the 
formative  cells  has  been  restored,  in  fact,  by  the  diseased  con- 
dition, the  tissue  is  broken  up,  to  a  certain  extent,  into  its  his- 
tological elements.  This  appearance  is  not  found  except  in 
dentine  which  has  acquired  a  cartilaginous  consistence,  in  con- 
sequence of  caries  ;  he  knows  of  no  artificial  means  whereby  the 
appearances,  such  as  have  been  described,  can  be  brought  about. 
He  also  discusses  the  vital  plienomena  which,  according  to  his 
view,  are  coincident  with  structural  changes  in  carious  dentine; 
under  this  head  he  includes  an  increased  sensibility  and  even 
painful  sensations,  chiefly  in  the  peripheral  portion  of  the  den- 
tine ;  after  the  destruction  of  vitality  in  this  part  of  the  tooth 
has  been  completed,  the  sensation  of  discomfort,  for  the  most 
part,  passes  away.  The  transparent  zone  in  the  vicinity  of  the 
carious  portion,  he  considers  to  be  due  to  the  consolidation  of 
the  dentinal  fibrils  within  the  tubes ;  a  reaction  on  the  part  of 
the  dentine  is  manifested  by  the  calcification  of  its  fibrils,  which 
necessarily  exercises  a  considerable  influence  in  arresting  the 
progress  of  disease.  He  refers  the  extraction  of  the  calcareous 
salts  to  the  acid  condition  of  the  mucus,  especially  to  that  of  the 
gums.  In  many  cases,  he  says,  an  acid  saliva  appears  to  cause 
a  rapid  destruction  of  the  teeth.  He  also  demonstrates  the  for- 
mation of  new  dentine  on  the  wall  of  the  pulp-cavity  correspond- 
ing to  the  carious  locality. 

Oudet*  considers  caries  to  be  a  disease  which  primarily  attacks 
the  dentine  exclusively,  and  secondarily  involves  the  contiguous 
portion  of  the  enamel. 

E.  Neumann!  endeavored  to  prove  the  vital  reactionary  power 
of  the  dentine  against  the  carious  process;  he  considered  the 
thickening  and  consolidation  of  the  tubes  and  fibres,  mentioned 
by  Tomes,  to  be  a  thickening  of  the  dentinal  sheaths,  at  the 
expense  of  the  basis-substance,  together  with  a  final  obliteration 
of  the  canals.  By  means  of  the  imbibition  of  carmine,  he  demon- 
strated, in  the  thickened  dentinal  fibres,  uncolored  and  brightly 
colored  segments,  alternating  with  each  other  with  considera- 

*  Rerherches  anatomiques,  phys.  et  microsp.  sur  les  dents,  1862. 
f  Archiv  fiir  kliniscbe  Chiriirgie,  Bd.  vi. 


37i  ANOMALIES    OF    THE    SECRETIONS. 

ble  uniformity,  and  is  inclined  to  regard  the  colored  portions  as 
nucleiforni  bodies.  Upon  an  eroded  ivory  peg  which  had  been 
driven  into  a  bone  in  the  treatment  of  a  pseudarthrosis,  he  was 
unable  to  detect  such  a  condition  as  is  presented  by  carious  den- 
tine ;  this  fact  he  regards  as  a  confirmation  of  his  view,  and 
considers  that  there  is  a  marked  correspondence  between  the 
changes  in  dental  caries  and  the  phenomena  presented  in  caries 
of  bone.  Between  caries  of  the  teeth  and  of  bone,  he  says,  the 
distinction  is  purely  formal,  depending  upon  the  difference  be- 
tween the  forms  of  the  cellular  elements  contained  in  each  of 
the  tissues  respectively,  the  roundish  bone-cells  on  one  side  and 
the  elongated  dentinal  fibres  on  the  other,  which  latter  become 
thickened  and  detached.  He  observed  a  calcification  of  the 
dentinal  fibres  only  in  one  instance,  and  remarks  that  the  latter 
is  referable  to  an  excessive  disposition  to  the  deposit  of  calcareous 
salts  at  the  expiration  of  an  inflammatory  pi'ocess,  a  phenomenon 
which  is  observed  in  bone. 

Magitot*  holds  the  opinion  that  caries  is  a  purely  chemical 
action  upon  the  enamel  and  dentine,  and  denies  the  existence 
of  a  caries  interna.  The  reaction  on  the  part  of  the  dentine, 
he  says,  is  manifested  usually  by  the  appearance  of  a  cone  or 
white  zone,  which  is  occasioned  by  obliterated  dentinal  canals  ; 
secondary  dentine  sometimes  is  formed  at  a  later  period  in  the 
pulp  ;  the  saliva,  he  observes,  is  the  cause  of  the  caries  when  it 
becomes  the  seat  of  acetous  fermentation,  or  the  vehicle  of  for- 
eign substances  which  act  directly  upon  the  enamel  and  dentine. 
Upon  the  authority  of  numerous  experiments,  he  asserts  that 
caries  may  be  induced  artificially  by  imitation  of  those  condi- 
tions which  occur  in  the  oral  cavity,  and  that  this  artificial 
caries  presents  the  same  characters  as  the  natural  form,  with 
the  exception  of  the  reactionary  phenomena. 

Hertzf  undertook  the  examination  of  caries  induced  by  artifi- 
cial fluids,  according  to  Magitot's  method,  and  also  of  a  number 
of  artificial  teeth  which  became  carious  within  the  mouth. 
He  found  merely  a  brownish-yellow  color  of  the  dentine,  to- 
gether with  disintegrated  and  decomposing,  larger  or  smaller 

*  Carie  dentaire,  1867.  f  Virchow's  Archiv,  Bd.  xli. 


HISTORY    OF    CARIES    OF    THE    TEETH.  37o 

portions  of  basis-substance.  He  found  nothing  abnormal  in  tlie 
dentinal  fibres,  and  hence  ho  coincides  with  the  view  that  the 
chanires  in  the  dentine  in  natural  caries  correspond  to  a  vital 
process.  As  pathological  appeanmces  of  tiie  dentinal  fibres,  he 
mentions  that  they  appear  swollen\  cloudy,  homogeneous  in 
character,  replete  with  fat-granules,  and  take  up  calcareoi;s 
salts,  and  these  he  considers  to  be  primary  affections. 

Th.  Leber  and  J.  llottenstein*  assert  that  there  are  no  recorded 
observations  which  authorize  the  assumption  of  an  active  reac- 
tion, a  kind  of  odontitis,  on  the  part  of  the  dentine  in  caries  of 
the  teeth,  and  that  caries  does  not  depend  upon  the  changes  re- 
ferred to  by  Tomes,  Neumann  and  others,  although  the  occur- 
rence of  very  slight  histological  changes  in  the  dentine  at  the 
commencement  of  the  process  cannot  be  denied  with  absolute 
certainty.  They  came  to  the  conclusion  by  proving  that  artifi- 
cially inserted  human  teeth,  which  have  become  carious  within 
the  mouth,  and  also  carious  teeth,  manufactured  out  of  ivory 
from  the  hippopotamus,  displayed  the  microscopic  changes  in 
the  dentine  which  were  regarded  as  proof  of  a  vital  process  in 
the  dentine.  They  treated  leptothrix  in  the  dentine  with  iodine 
and  acids  and  obtained  a  violet  color  of  the  widened  dentinal 
canals  which  were  filled  with  a  minutely  granular  mass,  and 
consider  it  to  be  indisputable  that  the  elements  of  the  fungus 
proliferate  within  and  extend  the  canals,  sometimes  to  a  consid- 
erable degree.  The  fungus,  they  add,  apparently  is  incapable 
of  penetrating  enamel  of  normal  hardness;  even  normally  hard 
dentine  offers  considerable  resistance  to  its  entrance,  if,  indeed, 
it  permits  it  in  the  least.  When,  however,  in  consequence  of 
the  action  of  the  acids  within  the  mouth,  the  enamel  and  den- 
tine have  lost,  somewhat,  their  power  of  resistance,  or  a  bi-each 
of  substance,  however  small,  has  been  produced  upon  the  sur- 
face of  the  dentine,  then  it  becomes  possible  for  the  fungus  ele- 
ments to  penetrate  into  the  interior  of  the  dental  substances, 
and  by  their  proliferation,  particularly  in  the  dentine,  to  occa- 
sion a  more  rapid  progress  of  the  softening  and  destructive  pro- 
cess than  would  have  been  the  case  under  the  action  of  the  acids 

*  Caries  der  Zahne,  18G7. 


376  ANOMALIES    OF    TUE    SECRETIONS. 

alone.  A  very  marked  destruction  of  the  teeth  within  the 
mouth,  they  say,  requires  a  participation  of  tlie  fungus ;  in  the 
earliest  stage,  only  while  the  surface  of  the  tooth  is  still  smooth 
and  intact,  is  the  fungus  undemonstrable,  and  hence  it  is  appar- 
ent that  in  this  stage,  that  of  dry  caries  properly  speaking,  tlie 
changes  are  to  be  ascribed  exclusively  to  the  action  of  acids. 

From  this  cursory  survey  of  the  various  theories  with  regard 
to  caries,  of  the  vital,  chemical,  and  parasitic,  with  their  combi- 
nations, the  advance  in  our  knowledge  becomes  apparent,  al- 
though the  interpretations  of  phenomena,  in  many  cases,  present 
wide  differences.  A  critical  consideration  of  the  views  Avhich 
have  been  adduced  will  be  found  in  the  following  pages,  in  con- 
nection with  the  theory  of  caries. 

Appeakances  Pp.esented  by  the  Enamel  in  Cakies, — Be- 
fore entering  upon  the  consideration  of  these,  we  must  allude  to 
the  cracks  or  fissures  in  the  enamel,  which  have  an  importance 
in  connection  with  the  developmicnt  and  extension  of  caries. 
During  life,  these  interruptions  of  continuity  are  observed  very 
frequently  upon  the  otherwise  healthy,  sound  teeth  of  young 
persons  and  especially  upon  those  of  persons  in  advanced  age, 
and  they  follow,  as  a  general  rule,  the  planes  of  cleavage  in 
the  enamel  (comp.  p.  30). 

Upon  close  inspection,  by  means  of  a  lens,  they  are  found  to 
be  much  more  numerous  than  one  would  suspect  at  first.  Not 
infrequently,  besides  the  principal  crack,  we  find  a  number  of 
smaller,  secondary  ones  which  unite,  in  some  cases,  so  as  to  form 
a  web,  and  in  others,  diverge  in  the  manner  of  rays.  Their 
edges  gape  only  in  exceptional  cases  and,  consequently,  there  is 
presented  an  appeai-ance  of  narrow  fissures. 

The  cracks  vary  in  character  in  the  different  kinds  of  teeth. 
The  enamel  of  the  incisors  not  infrequently  presents  upon  its 
labial  surface  one  or  even  several  straight  fissures,  reaching  from 
the  neck  to  the  incisive  edge;  usually  they  are  not  so  deep  as 
to  form  a  gap,  but  are  limited  to  the  superficial  layers.  Oblique 
cracks,  also,  occur  upon  the  lateral  portions  of  the  crowns  of 
these  teeth  and  extend  also  from  the  incisive  edges,  from  which 
particles  of  the  enamel  liave  been  broken  away.  Irregular, 
zigzag  fissures  sometimes  extend  from  the  edges  towards  the 


APPEARANCES  PRESENTED  BY  CARIOUS  ENAMEL.   377 

neck.  Sometimes,  when  the  edges  are  worn  down,  the  fissures 
extend  transversely  or  obliquely,  subdividing  here  and  there, 
across  the  abraded  surfaces  and,  consequently,  encroach  upon 
the  abraded  dentine. 

Upon  the  canines,  they  generally  extend  from  the  coronal 
apex  towards  the  neck.  Upon  the  bicuspids  and  molars,  longi- 
tudinal fissures  extend  from  the  coronal  cusps.  They  are  met 
with,  also,  in  the  grooves  of  the  latter  teeth.  When  the  cusps 
are  worn  away,  dichotomous  fissures  are  frequently  found  upon 
the  abraded  surfaces. 

Towards  the  neck  of  the  tooth,  where  the  enamel  becomes 
thinner,  closely  approximated  fissures,  which  often  intersect 
each  other,  are  of  very  frequent  occurrence  upon  all  the  teeth. 
Tbe  stellate  form  is  not  very  common  and  usually  originates  in 
a  minute  defect  in  the  enamel.  Longitudinal  fissures  in  the  in- 
terstitial frictional  surfaces  of  the  dental  crowns  are  quite  com- 
mon. Teeth  with  numerous  depressions  in,  and  excrescences 
uj)on,  the  enamel  often  contain  a  large  number  of  extremely  ir- 
regular fissures. 

Fissures  which  communicate  in  the  interior  of  the  substance 
are  frequently  met  with  in  the  dirty-grayish  or  brownish-discol- 
ored portions  from  commencing  caries,  and  in  these  cases  the 
conditions  presented  by  the  membrane  of  the  enamel  are  of 
especial  interest.  If  the  latter  be  removed  in  the  ordinary  way, 
by  means  of  dilute  hydrochloric  ncid,  manifold  perforations  are 
brought  into  view,  partly  in  the  transparent,  colorless,  partly  in 
the  thickened  portions  of  the  membrane  which  is  covered  with 
the  matrix  of  leptothrix  and  contains  deposits  of  pigment;  these 
are  distinguished  as  simple,  resembling  cleft-like  gaps,  and  com- 
pound. The  latter  form  a  system  of  ramifications  which  gradu- 
ally become  more  narrow,  presenting  an  appearance  not  unlike 
that  of  the  veins  on  the  leaf  of  a  plant,  and  are  more  likely  to 
be  found  in  that  part  corresponding  to  the  thinner  portion  of 
the  enamel  layer  towards  the  neck  of  the  tooth.  The  mem- 
brane in  the  latter  localities  usually  is  covered  with  a  uniformly 
disposed,  firmly  adherent  leptothrix  mass  (Atlas,  Fig.  83). 

A  minute  interruption  of  continuitij,  which  is  confined  to  nar- 
row limits,  manifests  itself  in  the  commencement  of  caries,  espe- 


d/8  ANOMALIES    OF    THE    SECRETIONS. 

ciallj  in  that  developmental  stage  in  Avluch  a  quite  light,  more 
or  less  white  spot  makes  its  appearance.  As  the  continuity  of 
the  enamel  prisms  becomes  interrupted,  the  corresponding  por- 
tion of  the  enamel  loses  its  transparency,  "-nd,  with  the  more 
extensive  rupture  of  their  cohesion,  the  einnnel  crumbles  awav, 
leaving  a  breach  of  varying  depth.  The  surface  of  the  cnamcd, 
corroded  as  it  "were,  is  uneven,  rough  and  full  of  holes.  White 
spots  occur  here  and  there,  independently  of  caries,  and  indi- 
cate an  imperfect  development  of  the  enamel  or  a  localized  (for 
some  time  at  all  events),  permanent  lax  condition  of  the  enamel 
prisms. 

The  pigment  deposits  in  the  enamel,  in  connection  with  caries, 
form  a  very  conspicuous  feature.  With  reflected  light  they  pre- 
sent various  shades  of  color,  from  brownish-red  to  blackish- 
brown,  a  dark-gray,  yellow,  or  yellow-gray ;  with  transmitted 
light,  they  are  tinged  with  a  vivid  brownish-red,  light  reddisli- 
yellow  or  deep-yellow  color.  The  pigment  is  limited  to  a  small 
portion  at  first  and  gradually  traverses  the  entire  thickness  of 
the  enamel ;  the  darker  shades,  iherefore,  are  found  near  the 
surface,  and  the  lighter,  in  the  deeper  enamel  layers;  a  dark  zone 
is  commonly  found  in  the  deepest  layers  adjoining  the  unaffected 
portions  of  the  enamel  (Atlas,  Figs.  87  and  88). 

The  outlines  of  the  portions  containing  deposits  of  pigment 
present  variations  which  depend  principally  upon  their  locality  ; 
where  the  enamel  dips  down  into  the  grooves  or  becomes  atten- 
uated towards  the  neck  of  the  tooth,  the  pigmented  portions  usu- 
ally occur  in  streaks  with  irregularly  wavy  outlines.  The  discol- 
orations,  particularly  in  the  thicker  portions  of  the  enamel,  fre- 
quently occur  in  the  form  of  a  cup  or  cone,  the  base  of  which  is 
directed  outwards,  sometimes,  but  more  frequently  inwards  to- 
wards the  dentine. 

Occasional!}^  in  chronic  caries,  streaks  or  spots  are  very  con- 
spicuous where  the  transparency  of  the  enamel  is  increased ; 
these  occur  within  circumscribed  limits  in  the  vicinity  of  a  por- 
tion discolored  by  the  presence  of  brown  pigment,  and  are 
brought  very  clearly  into  view  by  means  of  the  lens  and  with 
reflected  light.     The  structure  of  the  transparent  enamel  has  a 


APPEARANCES    PPvESENTED    BY    CARIOUS    ENAMEL.      379 

more  homogeneous  appearance  since  the  transverse  marl<ings  of 
the  prisms  are  less  distinctly  perceptible  than  in  other  localities. 

If  we  examine  thin  sections  of  carious  enamel  containing  de- 
posits of  pigment,  and  trace  out  its  various  shades  of  color,  we 
find  that  the  structure  of  the  enamel  is  wholly  unrecognizable 
where  the  coloring  matter  is  most  abundant  or  the  brown  pre- 
sents a  tinge  of  gray,  while  in  the  portions  containing  less  pig- 
ment, the  transverse  markings  of  the  enamel  are  very  con- 
spicuous and  the  transverse  striations  of  the  elementary  parts 
are  even  broader  in  appearance. 

The  diminution  in  the  consistence  (compactness)  of  the  por- 
tions which  become  the  seat  of  deposits  of  pigment  in  connection 
with  caries  is  an  important  element  in  the  process.  Scrapings 
from  the  surface  of  a  section  of  the  enamel  present  a  mortar- 
like disintegration,  powdered  fragments  of  enamel.  The  prisms 
lose  their  proper  transparency  and  the  homogeneity  of  their 
contents,  which  acquire  a  finely-porous  appearance,  is  de- 
stroyed. 

In  order  to  obtain  a  definite  idea  of  the  appearance  of  tJie 
enamel-cap  zvhen  it  presents  fissures  or  carious  spots,  it  is  ad- 
visable to  detach  the  cap  by  means  of  a  fifty  per  cent,  solution 
of  sulphuric  acid,  as  recommended  by  H.  Beigel.  For  this 
purpose,  teeth  should  be  selected  in  which  the  caries  is  not  very 
far  advanced,  because,  in  the  later  stages,  the  caps  easily  crum- 
ble. In  this  way,  a  clear  and  definite  view  of 
the  fissures  may  be  obtained.     In  the  molars.  Fir..  99.* 

deep  cracks  are  quite  common,  extending  from 
the  carious  portion  across  the  masticatory,  and 
aloncr  the  lateral  wall  of  the  enamel  cap,  and 
also  radiating  from  the  affected  portion  (Fig. 
99). 

At  the  same  time  Ave  are  enabled  to  compare 

*  Fig.  99  shows  numerous  fissures  with  several  holes  and  clefts  in  the 
enamel-cap  of  a  molar,  in  a  view  of  the  internal  or  dentinal  surface.  Most 
of  the  fissures  are  deep ;  some  of  them  extend  from  the  carious  portions  of 
the  masticatory  wall  upon  the  annular  or  lateral  wall  of  the  enamel-cap, 
here  and  there  presenting  ramifications.  In  this  case,  several  holes  and 
clefts  with  sharp  edges  and  no  deposit  of  pigment  in  the  adjoining  portions 


380  ANOMALIES    OF    THE    SECRETIONS. 

the  appearances  presented  by  the  carious  locality  upon  the  ex- 
ternal and  internal  surfaces  of  the  enamel-cap.  It  may  readily 
be  shown  that,  when  the  pigment  deposit  consequent  upon  caries 
is  limited  to  a  scarcely  perceptible  dark-brown,  minute  dot  upon 
the  masticating  surface,  it  is  more  extensive  upon  the  internal 
or  dentinal  surface  Avhere  it  has  a  roundish  or  jagged  outline. 
When  caries  in  the  groove  of  a  molar  tooth  is  displayed  in  the 
form  of.  a  very  narrow  streak  containing  pigment,  the  affected 
portion  upon  the  internal  surface  of  the  cap  measures  a  fourth 
of  a  millimetre  and  upwards.  When  a  cleft-like  loss  of  substance 
is  occasioned  by  caries,  the  portions  around  the  margins  of  the 
gap  contain  deposits  of  pigment  and  frequently 
^''^■'°*'*  are  thickened  somewhat  (Fig.  100).     The  pig- 

y^i^^^^^v      ment  deposits,   consequent    upon    caries,  -which 
/  occur   in    the   contiguous   coronal   surfaces   and 

I  >.      usually   have   a   li";ht   or    gravish-brown    color, 

v  penetrate  the  entire  thickness  of  the  enamel  at 

first  only  in  the  thinnest  portion  near  the  neck 
of  the  tooth. 
It  happens,  sometimes,  that  a  portion  of  the  summit  of  the 
still  hard  dentine,  with  a  brownish-yellow  pigment  deposit  cor- 
responding with  the  carious  locality,  remains  unaffected,  while 
the  rest  of  the  dentine  is  destroyed  by  the  boiling  dilute  sul- 
phuric acid.  It  has  not  yet  been  determined  whether  or  not  a 
casual,  unusually  great  power  of  resistance  on  the  part  of  the 
dentine  is  to  be  assigned  as  the  reason  for  this  occurrence. 

If  we  select  a  series  of  teeth  which  are  affected  with  caries  in 
its  earlier  stages  and  belong  to  the  different  periods  of  life,  and 
treat  them  with  very  dilute  hydrochloric  acid,  it  may  readily  be 

of  the  enamel  are  to  be  observed  ;  these  are  not  the  results  of  abrasion  or 
caries,  but  are  to  be  regarded  as  defects  in  the  formation  of  the  enamel. 
Magnified  2  diameters. 

*  Fig.  100  — Interior  view  of  the  enamel-cap  from  a  molar  affected  with 
chronic  caries.  The  latter  occurred  in  the  crucial  groove.  The  wall  cor- 
responding to  the  masticating  surface  presents  a  few  gaps  and  several  dark 
spots  ;  the  enamel  tissue  in  the  vicinity  of  the  former  and  in  the  latter  had 
a  dirtj'-grayish  and  reddish-brown  color,  and  is  fissured  and  full  of  excava- 
tions; the  carious  attection  is  more  extensive  upon  the  inner  than  upon  the 
outer  surface.     Magnified  2  diameters. 


APPEARANCES    PRESENTED    BY    CARIOUS    ENAMEL.       381 

demonstrated  that  the  portion  of  the  detached  enamel  membrane 
corresponding  to  the  carious  locality  has  undergone  a  perceptible 
thickening.  The  transparent  membrane,  moreover,  where  the 
transition  into  the  carious  portion  is  apparent,  is  clouded,  brit- 
tle and  variously  stained.  The  colors  vary  between  gray, 
grayish-brown,  brownish-yellow,  syrupj^-brown,  reddish-brown, 
and  reddish-yellow.  With  regard  to  the  cnrious  localities,  it  is 
to  be  borne  in  mind  that  one  has  to  do  not  only  with  the  mem- 
brane of  the  enamel,  but  also  with  the  organic  remains  of  the 
enamel. 

The  frequent  gray  cloudiness  presented  by  the  detached  mem- 
brane is  found  to  be  due  to  a  uniformly-diffused  mass  of  granules 
of  nearly  equal  size  and  arranged  side  by  side  and  over  one 
another  at  uniform  distances.  The  molecular  mass  is  the  so- 
called  matrix  of  leptothrix  buccalis  which  is  united  so  intimately 
with  the  enamel  membrane  and  the  organic  remains  of  the 
enamel  that  together  they  form  an  inseparable  whole.  The 
thickness  of  the  matrix  varies,  and  the  thickening  of  the  mem- 
brane is  due,  in  a  great  measure,  to  the  latter;  the  brittleness 
and  friability  of  this  membrane,  also,  is  occasioned  by  the  super- 
position of  the  matrix.  As  proof  that  the  latter  appertains  to 
the  leptothrix  may  be  adduced  the  fact  that  it  is  not  uncommon 
to  find  tufts  of  leptothrix  threads  hanging  from  the  edges  of  the 
granular  mass. 

The  brown  portions  present  light  or  dark-brown,  transparent, 
homogeneous  masses  which  are  fissured  in  such  a  manner  as  to 
display  a  lamina  composed  of  irregular  polygons.  The  perfora- 
tion of  the  enamel-membrane,  mentioned  above  as  resembling 
the  nerves  of  a  leaf,  presents  a  strong  resemblance  in  its  con- 
figuration to  the  brown  mass  in  question  ;  the  latter,  however, 
is  thicker  and  proceeds  from  the  enamel  which  is  deprived  of  its 
calcareous  salts,  transformed  into  a  homogeneous  mass  and 
foraminated. 

The  familiar  mosaic  appearance  produced  by  the  transverse 
division  of  some  of  the  prisms  is  beautifully  shown,  in  some 
cases,  after  the  extraction  of  the  calcareous  salts  from  carious 
enamel.  Some  of  the  prisms  contain  a  homogeneous,  highly 
refracting,  light  or  dark  brown,  and  others  a  granular,  mass  of 


382  ANOMALIES    OF    THE    SECRETIONS. 

a  similar  color  (Atlas,  Fig.  84).  The  persistence  of  the  contours 
of  the  enamel  prisms  in  places  after  treatment  Avith  acids  is  un- 
explained, at  present.  Possibly  it  may  be  due  to  the  prolifera- 
tion of  a  leptothrix  mass  into  the  decalcified  enamel. 

The  carious  enamel  sometimes,  also,  is  transformed  into  a 
coarse-granular,  brown  mass ;  now  and  then  the  granules  are 
blended  together  and  are  to  be  regarded  as  the  organic  remains 
of  the  shrivelled  enamel-prisms.  The  mass  is  intimately  united 
with  the  enamel-membrane,  upon  the  outside  of  which,  in  many 
places,  is  located  the  matrix  together  with  the  attached  threads 
of  leptothrix. 

When  the  deposits  of  pigment  impart  a  blackish-brown  color 
to  the  carious  enamel,  the  prisms  are  no  longer  distinguishable. 
After  the  extraction  of  the  calcareous  salts  from  the  enamel, 
there  is  left,  sometimes,  a  brittle,  friable,  blackish-brown  mass 
which  presents  sharp  and  angular  edges  when  broken.  In  the 
later  stages,  the  enamel-membrane  acquires  a  syrupy-brown 
discoloration. 

When  the  carious  enamel  presents  superficial  greenish  spots, 
this  color  is  participated  in  by  the  externally-attached  matrix 
of  leptothrix,  the  enamel-membrane  and  even  the  organic  re- 
mains of  the  enamel-prisms,  to  a  varying  degree. 

If  so-called  eroded,  cribriform,  foraminated  [honeycombed], 
and,  consequently,  irregularly-developed  enamel,  Avhich  is  af- 
fected with  commencing  caries,  be  decalcified,  the  enamel-mem- 
brane Avill  display  an  alveolate  appearance,  i.  e.,  it  presents 
round,  sharp-edged  pits  of  various  sizes,  within  which  the  mem- 
brane is  thinner  and  perhaps  wanting  entirely,  here  and  there, 
and  a  leptothrix-mass  has  taken  up  its  abode.  Between  the 
light-colored  alveoli  lies  a  yellow,  syrupy-brown  substance. 

In  many  cases,  the  remaining  organic  matter  of  the  enamel 
from  the  teeth  of  old  persons,  which  are  aifected  with  commencing 
caries,  presents  the  appearance  of  a  diffluent,  coagulated,  trans- 
parent, structureless,  effused  substance,  in  the  interstices  of 
which  is  lodged  a  molecular,  dirty-gray  leptothrix  mass. 

Usually  in  the  course  of  the  process,  an  undermining  caries 
of  the  enamel  is  met  with,  ^.  c,  the  caries  is  more  extensive  in 
the  deeper  layers  of  enamel   than   is  apparent  externally  upon 


APPEARANCES  PRESENTED  BY  CARIOUS  ENAMEL.   383 

the  surface,  jnst  as  if  the  process  commenced  in  <i  groove,  de- 
pression, or  fissure.  The  particles  of  enamel  crumble  away 
and  are  detached,  leaving  a  gap  or  a  pit  which  increases  in  ex- 
tent in  the  deeper  layers.  Tiie  undermined  portion  may  easily 
be  broken  away,  when  the  enamel  upon  the  excavated  surface 
may  be  scraped  off,  displays  a  chalky  or  mortar  like  disintegra- 
tion, often  presents  a  dirty-brown  color  and  contains  the  frag- 
ments of  enamel-prisms.  As  might  be  anticipated,  the  dentine 
is  exposed  to  greater  danger  by  this  undermining  process;  it  is 
denuded  to  a  greater  extent  and  subjected  to  the  action  of  in- 
jurious external  agents.  When  the  deposit  of  pigment  in  the 
carious  enamel  takes  place  in  the  form  of  a  cone  with  its  base 
directed  externally,  the  affection  of  the  dentine  is  confined  to 
more  narrow  limits. 

Heider  informed  me  that  caries  of  the  enamel  frequently 
escapes  clinical  observation  at  its  commencement,  and  that  this 
is  the  more  likely  to  be  the  case  since  at  this  stage  the  disease 
gives  the  patient  no  uneasiness  and,  usually,  occurs  at  points 
which  cannot  be  seen  except  with  difficulty.  By  a  careful  ex- 
amination with  a  very  fine  probe  and  mouth-mirror,  a  slight 
roughness  is  detected  in  the  enamel  which  may  readily  be  re- 
moved with  a  sharp  instrument.  By  means  of  the  mirror  the 
color  is  brought  into  view ;  this  varies  according  to  circumstances, 
and  is  particularly  distinct  with  those  teeth  which  it  is  possible 
to  examine  in  the  mirror  with  the  light  transmitted  through 
them,  as,  for  instance,  with  the  posterior  surface  of  the  incisors 
when  they  are  examined  in  the  mirror  with  the  light  falling 
directly  upon  them.  A  diffused  cloudiness  with  a  quite  dark 
central  portion  characterizes  the  pi'imary  appearance  of  caries, 
before  a  pit-like  breach  of  substance  is  produced  by  the  disin- 
tegration of  the  enamel.  Observed  in  the  above  manner,  the 
color  of  the  spot  varies  from  a  chalky-white  to  a  bluish-white, 
and  is  gray,  brown,  and  black. 

These  different  colors,  however,  do  not  correspond  to  different 
stages  of  the  process,  but  characterize  the  various  modifications 
of  the  same.  The  lighter  the  spot,  the  deeper  extends  the  de- 
struction and  the  more  rapid  is  the  progress  of  the  disease.  The 
darker  the  color,  the  more  limited  and  circumscribed  is  the  dis- 


384  ANOMALIES    OF    THE    SECRETIONS. 

colored  portion  of  the  enamel,  and  the  slower  is  tlie  course  of 
the  aifeotion. 

Let  the  discoloration  be  what  it  may,  the  subsequent  patho- 
logical changes  in  tlie  enamel  present  a  tolerable  degree  of  uni- 
formit}'.  The  connection  existing  between  its  constituent  ele- 
ments becomes  broken.  Oftentimes,  also,  a  fissure  may  be 
detected,  which  bisects  the  discolored  portion.  If,  however, 
this  is  not  the  case,  the  enamel  is  always  found  to  be  perforated 
with  holes,  is  friable,  breaks  up  and  crumbles  away,  and  in  this 
way  the  already  more  or  less  softened  dentine  becomes  denuded. 

In  the  primary  stage,  that  of  discoloration,  the  process  which 
has  been  described  is  entirely  painless.  When  perforation  com- 
mences, patients  who  are  attentive  to  their  teeth  experience,  at 
first,  especiall}^  during  the  mastication  of  a  very  firm  substance, 
an  unpleasant  sensation  which  is  induced  by  partaking  of  acids, 
fruit,  syrup  and,  sometimes,  even  by  sudden  changes  of  tem- 
perature. Generally,  however,  this  sensation  escapes  observa- 
tion and  the  patient  is  first  made  aware  of  the  destruction  Avhich 
has  taken  place,  by  the  occurrence  of  occasionally  severe,  but 
transitory  pains,  occasioned  by  the  impaction  of  particles  of  food 
Avithin  the  deep  cavities  where  the  surface  of  the  dentine  has 
been  extensively  denuded. 

Appearances  Presented  by  the  Dentine  in  Caries. — 
That  portion  of  the  dentine  which  lies  beneath  the  enamel-cap 
becomes  involved  before  the  deposit  of  pigment  in  the  carious 
enamel  has  reached  the  dentinal  bound;iry  (Atlas,  Figs.  87  and 
88).  Tlie  affection  of  the  dentine  is  manifested  by  a  diminished 
translucency  and  a  diseoloration  of  the  corresponding  portion  of 
the  dentinal  crown.  The  portion  adjacent  to  the  enamel  boun- 
dary has  a  very  intense,  reddish-brown  color;  this  passes  into 
a  reddish-yellow  Avhich,  finally,  becomes  a  straw  color  towards 
the  central  portion.  The  opaque  condition  forms  a  greater  or 
less  contrast  with  that  of  the  adjacent  dentine.  In  most  cases, 
the  affected  portion  of  the  periphery  of  the  dentine  assumes  the 
form  of  a  cone,  the  base  of  which,  directed  outwards  towards 
the  enamel,  is  broad  in  comparison  with  the  discolored  portion 
of  the  enamel.  The  apex  of  the  cone  is  directed  towards  the 
central  portion,  and  it  is  evident  that  the  configuration  of  the 


APPEARANCES    PRESENTED    BY    CARIOUS    DENTINE.      385 

cone  is  occasioned  by  the  radiation  of  the  dentinal  canals.  This 
disposition,  however,  does  not  always  obtain  in  respect  of  the 
opacity  and  discoloration;  it  is  far  more  common  to  find  lateral 
prolongations  from  the  carious  dentinal  cone.  The  yellowish 
pigment  not  infrequently  is  distributed  with  great  irregularity, 
extends  to  a  considerable  depth  in  the  carious  dentine,  and  gives 
rise  to  the  appearance  of  insulated  patches  of  yellowish,  discol- 
ored dentine,  in  transverse  and  longitudinal  sections. 

The  still  compact,  affected  portions  of  the  dentine  present  a 
clouded  appearance,  due  in  part  to  the  presence  of  grains  which 
have  a  linear  arrangement,  are  spherical,  for  the  most  part, 
sometimes,  also,  elongated,  and  fill  the  cavities  of  the  dentinal 
canals.  This  granular  condition  is  very  perceptible,  also,  in  the 
yellowish  discolored  portions  and  even  in  the  interglobular  masses. 
The  cloudiness  in  the  canals  not  infrequently  is  due  to  a  molec- 
ular condition,  and  in  this  connection  I  will  merely  remark  that 
it  is  morphologically  identical  with  that  met  with,  both  in  the 
vicinity  of  the  abraded  surfaces  and  of  the  cement,  in  the  canals 
of  senile  teeth  which  have  been  worn  down  to  the  dentine  but 
do  not  contain  the  least  trace  of  caries. 

It  is  a  difficult  matter  to  determine  the  nature  of  these  grains, 
but  I  have  no  doubt  that  they  belong,  for  the  most  part,  to  liquid 
fat.  If  thin  sections  of  the  dentine  in  question  be  subjected  to 
the  action  of  dilute  hydrochloric  acid,  a  number  of  drops,  ex- 
actly resembling  fat-globules,  always  make  their  appearance, 
both  upon  the  surfaces  and  edges  of  the  sections;  indeed,  they 
are  often  found  in  the  interior  of  a  canal.  If  a  section  of  den- 
tine of  this  description  be  decalcified  completely,  by  means  of 
dilute  hydrochloric  acid,  and  then  carefully  boiled  with  the 
same  acid,  in  order  to  effect  the  familiar  isolation  of  the  pro- 
cesses of  the  dentinal  cells,  we  obtain,  in  some  places,  grains 
arranged  in  the  form  of  a  chaplet  and  diminishing  in  size  to 
that  of  minute  molecules,  and  in  others,  varicous  processes,  the 
contents  of  which  present  the  glitter  of  fat.  Many  of  the  pro- 
cesses remain  entirely  free  from  this  metamorphosis;  from  many 
others  the  fat  obviously  has  been  pressed  out  and  the  globules 
have  united  to  form  drops.  The  appearance  is  exactly  similar 
to  that  obtained  from  senile,  much  worn  dentine  (Atlas,  Fig.  95). 

25 


386  ANOMALIES    OF    THE    SECRETIONS. 

If,  on  the  other  hand,  the  question  be  asked  if  the  fine  gran- 
ules do  not  belong  to  leptothrix,  in  my  opinion,  a  negative  reply 
should  be  given.  I  have  been  unable,  in  this  primary  stage  of 
the  carious  affection  of  dentine,  to  obtain  a  reaction  from  the 
treatment  of  leptothrix  with  iodine  and  acids,  according  to  the 
method  suggested 'by  Leber  and  Rottenstein. 

The  discoloration  of  the  carious  dentine  extends  to  the  canals 
and  intertubular  tissue  and  is  intense  even  in  very  thin,  trans- 
verse sections.  The  interglobular  masses,  also,  contain  deposits 
of  pigment.  Coincident  with  the  development  of  the  opacity 
and  the  pigmental  degeneration,  in  the  commencement  of  the 
cai'ious  affection  of  the  dentine,  an  increased  translucency  is  ob- 
served, frequently,  in  the  portions  adjacent  to  the  boundary  of 
the  carious  portion.  With  reflected  light,  these  portions  have  a 
horny  appearance,  similar  to  that  found  in  senile  roots,  and,  with 
transmitted  light,  they  present  hyaline  bands  and  spots.  The 
focus  (Herd)  of  the  caries  is  surrounded  by  a  diaphanous  halo. 
The  opaque,  carious  dentinal  cone,  therefore,  is  invested  by  a 
translucent  zone,  extending  from  the  periphery  towards  the  cen- 
tre; around  a  more  spherical,  carious  portion  of  the  dentine,  a 
crescentic  diaphanous  halo  is  met  with  sometimes.  .The  light 
portions,  finally,  vary  exceedingly  in  respect  of  their  outlines, 
according  to  the  form  in  which  the  carious  limits  are  extended, 
being  radiated,  kidney-shaped,  &c.  (Atlas,  Fig.  91). 

No  diminution  in  the  compactness  of  such  dentine  can  be  de- 
tected, and  it  is  an  easy  matter  to  prove  the  impossibility  of  the 
admission  of  air  into  the  desiccated  dentinal  canals.  I  have 
been  unable,  in  thin  sections,  to  discover  a  further  anomaly 
in  the  tissue.  J.  Tomes*  speaks  of  a  consolidation  of  the  den- 
tinal fibrils  as  being  the  cause  of  the  translucency,  and  regards 
the  fibrils  as  calcified,  since,  in  thin  sections,  made  with  a  sharp 
knife  from  a  well-selected  tooth  in  the  direction  taken  by  the 
dentinal  tubes  from  the  discolored  portion,  he  saw  the  fibrils 
within  the  tubes  broken  into  short  fragments.  These  statements 
may  be  correct,  but  Tomes  has  yet  to  prove  the  calcification  of 
the  fibrils,  since  he  neglected  to  try  the  reaction  with  acids ; 

*  Op.  cit.,  p.  313. 


APPEARANCES  PRESENTED  BY  CARIOUS  DENTINE.   387 

moreover,  the  evidence  obtained  from  preparations  made  in  such 
a  manner  are  not  to  be  depended  upon. 

If  the  carious,  discolored,  but  still  compact  dentine  remains 
denuded  for  some  time,  exposed  to  the  action  of  external  agents, 
and  any  acid  be  allowed  to  act  upon  its  surface,  a  decalcifying 
process  will  ensue  and  that  condition  will  be  induced  which  is 
termed  cartilaginous  softening.  In  many  cases,  this  is  a  very 
slow  process  and  even  appears  to  be  arrested  for  a  time,  while 
it  takes  place  rapidly  in  some  cases.  The  latter  form  is  desig- 
nated commonly  as  acute,  moist  caries,  in  contradistinction  to 
the  former  which,  more  properly,  is  termed  chronic. 

When  the  dentine  has  become  deprived  of  its  calcareous  salts 
to  an  extent  sufficient  to  admit  the  insertion  of  a  needle,  a  super- 
ficial disintegration  ensues.  Leber  and  Rottenstein,  therefore, 
Avith  reason,  divided  the  carious  affection  of  the  dentine  into 
two  stages  which,  however,  cannot  always  be  nicely  discrimi- 
nated, a  preparatory  stage  of  decalcification  and  softening  and 
a  stage  of  direct  disintegration. 

Upon  the  examination  of  dentine  which  has  undergone  the 
cartilaginous  softening  and  may  be  cut  with  a  knife,  no  marked 
change  can  be  detected,  except  a  yelloAvish,  reddish-yellow,  red- 
dish-brown discoloration;  the  dentine  presents  an  appearance 
as  if  it  had  been  decalcified  by  means  of  hydrochloric  acid  and 
subsequently  dyed.  Localities,  however,  are  observed,  chiefly 
in  cases  where  the  softening  has  been  very  extensive,  in  Avhich 
the  dentine  has  undergone  such  a  remarkable  alteration  that  it 
can  scarcely  be  recognized  as  human  dentine,  a  metamorphosis 
which  was  discovered  by  J.  Tomes  and  has  been  confirmed  by 
numerous  writers. 

In  sections  made  in  a  direction  transverse  to  the  axes  of  the 
radiating  dentinal  canals,  a  greater  or  less  number  of  canals  are 
met  with,  whose  limiting  walls  (the  so-called  dentinal  sheaths) 
describe  unusually  large  circles,  and  whose  cavities  are  replete 
with  a  mass  which  has,  in  some  places,  a  homogeneous,  in  others, 
a  molecular  appearance  and  forms  convex  projections  beyond 
the  surface  of  the  section  (Atlas,  Fig.  02).  The  transverse  di- 
ameters of  the  widened  and  filled  canals  vary,  some  being  at 
least  three  times  as  large  as  others.     The  intertubular  tissue 


388  ANOMALIES    OF    THE    SECRETIONS. 

presents  a  molecular  cloudiness  and  is  beset  ■with  grains  having 
the  appearance  of  fat.  In  sections  made  parallel  to  the  long 
axes  of  the  canals,  thej  are  quite  clearly  seen  to  be  unequally 
filled  by  the  foreign  mass,  since  they  present  manifold  varicosi- 
ties and  constrictions  v/hich,  also,  explain  the  variations  in  the 
diameters  of  the  widened  canals. 

If  a  section  made  in  the  direction  of  the  varicous  canals  is 
boiled  for  some  time  in  water  or  in  very  dilute  hydrochloric 
acid,  until  it  begins  to  break  up  into  delicate,  fimbriated  tufts, 
in  other  words,  if  the  dentinal  fibres  or  processes  of  the  dentinal 
cells  are  isolated,  a  still  more  definite  idea  of  the  various  degrees 
of  thickenings  and  knotty  swellings  of  the  same  may  be  ob- 
tained. A  molecular  mass  covers  these  fibres  nearly  every- 
where ;  sometimes,  also,  they  present  transverse  fissures  which 
give  to  them  a  peculiar,  as  it  were,  scarified  appearance.  Mi- 
nute grains,  also,  like  the  head  of  a  pin,  rest  upon  the  fibres  at 
tolerably  uniform  intervals  from  one  another  and  are  highly 
suggestive  of  Micrococcus.*  Lateral  branches  are  given  off 
from  the  fibres  at  fixed  angles  (Atlas,  Fig.  95).  In  consequence 
of  the  blending  of  the  intertubular  tissue,  a  considerable  number 
of  fat-globules  are  produced,  which,  in  many  places,  impart  a 
notable  cloudiness  to  the  cartilaginous  softened  dentine. 

The  question  naturally 'arises,  Avhat  is  the  nature  of  the  mass 
which  fills  the  canals  ?  Leber  and  Rottenstein,  by  a  fortunate 
application  of  an  iodine  solution  and  acid,  succeeded  in  demon- 
strating the  proliferation  of  leptothrix  buccalis  in  the  softened 
dentine.  One  may  readily  convince  himself,  both  in  longitudi- 
nal and  transverse  sections,  of  the  violet  color  which  is  im- 
parted to  the  contents  of  the  canals.  Hence,  by  their  prolif- 
eration, the  grains  of  leptothrix  occasion  the  manifold  swellings 
and  varicous  enlargements  of  the  fibres,  and  are  so  closely  ce- 
mented together,  that  their  connection  cannot  be  broken  even 
after  the  action  of  heated  hydrochloric  acid. 

*  Upon  a  very  close  examination  of  the  disintegrating  portions 
of  the  superficial  softened  dentine,  the  matrix  of  leptothrix 
may  be  found  everywhere  in  the  perforations;  irregular  chan- 

*  Comp.  Karsten,  Chemismus  der  Pflanzcnzelle,  1869,  p.  25. 


APPEARANCES    PRESENTED    BY    CARIOUS    DENTINE,      389 

nels,  spherical  cavities,  -wliicli  are  found,  here  and  there,  still 
connected  with  a  thickened  fibre,  are  replete  with  the  matrix. 

In  consequence  of  the  superficial  disintegration  of  the  den- 
tine, there  arises,  at  first,  a  shallow  indentation  which,  however, 
shortly  acquires  larger  dimensions  when  the  caries  undermines 
the  dentine,  as  is  the  case  nearly  always  in  the  acute  form.  A 
cavity  with  a  narrow  outlet  is  formed  which  contains  the  so- 
called  carious  matter.  Particles  of  food,  forced  into  this  during 
mastication,  easily  become  impacted,  and  give  rise  to  a  process 
of  fermentation  ;  sometimes,  innumerable  monads  are  found 
moving  in  the  fluid  vehicle,  and  upon  the  wall  of  the  cavity  are 
attached  large  masses  of  leptothrix  and  linked  chains  of  oidium. 
Fragments  of  dentine,  which  have  not  been  decalcified,  some- 
times exfoliate  during  the  undermining  process  and  are  of  fre- 
quent occurrence  within  the  cavity.  In  the  dried  condition,  the 
wall  of  the  cavity  has  a  gray,  grayish-brown,  dirty  yellowish- 
brown  color,  or  it  is  not  uncommon  for  it  to  be  colorless,  like 
asbestos,  and  the  loosened  dentinal  layers  may  be  detached  in 
fragments  or  thin  lamellse,  by  means  of  a  needle. 

If  the  carious  cavity  has  extended  so  far  that  nothing  but  a 
thin  layer  of  dentine  separates  it  from  the  pulp-cavity,  or  it  has 
reached  the  pulp,  then  occur  those  constant  pains  which  are  in- 
duced by  inflammation  of  the  pulp  (compare  p.  176). 

Exceptional  cases  occur  where  the  destruction  of  a  large  por- 
tion of  the  crown  of  the  tooth  may  be  accompanied  by  very 
slight,  if  any,  pain.  This  fjict  may  be  ascribed,  in  part,  to  a 
generally  diminished  sensibility  on  the  part  of  the  individual, 
but,  for  the  most  part,  it  is  due  to  an  atrophy,  a  calcification,  or 
a  dentinal  new-formation  corresponding  to  the  carious  locality. 

Cases  of  caries  of  the  dentine  ivlncli  runs  a  chronic  course 
difl'er  from  the  foregoing  in  that  the  decalcification  and  disinte- 
gration progress  slowly.  While,  in  acute  cases,  months  only,  in 
chronic  cases  as  many  years  are  required  for  the  destruction  of 
the  crown  of  a  tooth.  Between  these  two  extremes,  a  large 
number  of  cases  occur  which  have  a  longer  or  shorter  duration. 
In  the  moist,  acute  caries,  the  discoloration  of  the  affected  den- 
tine is  of  a  light  shade,  the  lighter  the  shorter  the  duration  of 
the  disease,  and  the  cartilaginous  softening  acquires  a  notable 


390  ANOMALIES    OF    THE    SECRETIONS. 

extent,  Avbile,  on  the  otlicr  hand,  in  the  chronic  form,  the  dis- 
coloration is  of  a  darker  hue,  and  the  consistence  of  the  nearly 
black  dentine  is  slightly  diminished.  The  reaction  of  the  con- 
tents of  the  carious  cavity  with  litmus-paper,  also,  furnishes  a 
familiar  element  of  distinction  between  the  two  forms,  namely, 
a  more  strongly  marked  acid  reaction  is  given  in  cases  where 
the  destruction  is  most  rapid.  The  cartilaginous  softened  layer 
of  the  dentine  has  a  marked  acid  reaction,  while  in  connection 
with  chronic  destruction  the  latter  is  not  decided. 

The  dark  shaded,  consistent,  carious  dentine  occasionally  dis- 
plays a  very  narrow  zone  of  cartilaginous  softening,  but  in  well- 
marked  chronic  cases,  this  cannot  be  identified.  In  the  latter, 
therefore,  we  have  to  do  with  very  dry  caries.  A  dark  powder 
containing  the  fragments  of  dentine  may  be  scraped  off  by 
means  of  a  sharp  knife,  and  besides  the  dark-brown  discolora- 
tion, no  other  anomaly  is  presented  by  the  dentine.  I  have 
been  unable  to  satisfy  myself  of  the  calcification  of  the  fibrils 
in  these  cases. 

In  the  course  of  chronic  caries,  the  dentinal  layers  exfoliate, 
the  surface  of  the  affected  portion  is  rough,  as  if  it  had  been 
scratched  with  a  sharp  instrument ;  as  the  dentine  disappears, 
there  is  left,  at  first,  a  minute,  gradually  enlarging,  carious  in- 
dentation with  a  sharp  margin  and  a  blackish-brown  discolored 
wall. 

When  the  coronal  dentine  is  aifected  primarily,  as  sometimes 
happens  when  the  masticating  surfaces  have  been  worn  aAva}' 
very  much,  bands  and  spots  make  their  appearance,  having 
a  color  varying  between  dark-brown  and  black  and  invested 
by  a  quite  broad,  light-brown  uniform  zone.  Both  discolora- 
tions  extend  nearly  to  the  wall  of  the  pulp-cavity.  In  such 
cases,  frequentlj^  it  is  a  matter  of  doubt  whether  we  have  to  do 
with  dental  caries  or  with  senile  necrobiosis.  One  must  be  care- 
ful not  to  pronounce  every  brownish  discoloration  of  the  den- 
tine to  be  caries  (compare  remarks  upon  the  senile  changes  in 
dentine,  p.  242). 

Thin  sections  of  dentine  affected  with  well-marked  chronic 
caries  display  a  dark  pigmental  degeneration,  but  no  other 
structural  change ;  it  is  especially  noticeable  that,  even  after  a 


APPEARANCES    PRESENTED    BY    CARIOUS    CEMENT.      391 

preliminary  decalcification,  they  present  no  expansions  of  the 
dentinal  canals  containing  proliferating  leptothrix  and,  more- 
over, that  grains  and  threads  of  leptothrix  are  rarely  met  with 
upon  the  surfiice  of  the  carious  dentine. 

Appearances  presented  by  the  Cement  in  Caries. — Caries 
makes  its  appearance  upon  the  7ieck  of  the  tooth,  usually  in  the 
vicinity  of  the  border  of  the  enamel,  and  commences  in  the 
form  of  a  discoloration  (barely  perceptible  at  first,  and  of  a 
brownish  tinge)  of  the  cement  layer  which,  in  this  locality,  is 
very  thin.  In  a  short  time,  the  latter  is  destroyed,  the  dentine 
becomes  affected,  the  enamel  attached  to  the  neck  becomes  un- 
dermined by  the  formation  of  a  carious  excavation  and  projects 
in  the  form  of  a  lamella  with  sharp  edges.  The  excavation, 
shallow  at  first,  becomes  more  extensive  as  the  carious  process 
spreads  from  the  border  into  the  adjoining  portions  of  the  neck. 
A  cavity  of  considerable  size  is  developed  by  the  carious  pro- 
cess, which  usually  occurs  in  the  more  acute  form,  and  the 
danger  to  the  tooth  is  measured  by  the  extension  of  the  caries 
around  the  neck. 

If  a  portion  of  the  root  of  the  tooth  is  deprived  of  its  bony  and 
membranous  covering,  in  consequence  of  the  wasting  of  the  alve- 
olus, the  carious  process  may  attack  the  cement  of  the  root  pri- 
mariJt/  and  produce  one  or  several  breaches  of  substance,  up  to 
the  size  of  a  pin's  head,  which  extend  through  the  entire  thick- 
ness of  the  dentine  and  occasion  a  denudation  of  the  correspond- 
ing portion  of  the  root-pulp,  as  the  disease  advances.  These 
carious  excavations  usually  have  sharp  edges,  are  patelliform 
and,  occasionally,  occur  without  an  affection  of  any  other  por- 
tion of  the  tooth. 

Caries  of  the  cement  presents,  at  first,  a  more  or  less  circum- 
scribed, yellow  or  brown  discoloration,  without  any  other  change 
of  the  bony  substance.  Perforations  immediately  begin  to 
make  their  appearance,  which  extend  from  without  internally 
and  give  rise  to  a  disintegration  and  breach  of  the  superficial 
layers  of  the  cement.  The  surface  of  the  discolored  cement 
also  acquires  an  eroded  appearance  and  is  beset  with  shallow 
pits  with  serrated  edges.     When  the  caries  extends  from  the 


392  ANOMALIES    OF    THE    SECRETIONS. 

cement  to  the  dentine,  tlie  latter  becomes  perforatetl,  usually  in 
the  direction  of  the  dentinal  canals. 

Extension  of  Caries  to  the  Roots  of  the  Teeth. — If  the 
coronal  portion  be  undermined  by  caries,  extending  from  the 
masticating  surface,  the  surfaces  adjacent  to  the  contiguous 
teeth,  or  from  the  neck,  so  that  a  large  cavity  with  a  fragile, 
shell-like  wall  is  formed,  the  latter  gradually  crumbles  away 
leaving  merely  the  corresponding  roots.  Although  the  carious 
process  may  have  run  a  well-marked  acute  course  in  the  coronal 
portion,  it  is  much  more  protracted  in  the  roots,  and  as  Hunter 
asserted  long  ago,  it  is  a  rare  occurrence  to  meet  with  a  root 
which  has  been  excavated  as  far  as  its  apex.  The  process  ap- 
pears to  be  suspended,  sometimes,  or  at  all  events,  to  advance 
very  slowly.  The  carious  excavation  usually  is  shallow,  the 
elevated  edges  frequently  are  attenuated  and  jagged.  In  one 
instance,  only,  I  have  met  with  a  flask-shaped  cavity  with  a  nar- 
row outlet.  The  extremities  of  the  root  become  blunted,  rounded 
and  discolored,  this  condition  being  more  conspicuous,  the 
smaller  the  portion  of  the  root  which  is  retained. 

After  the  destruction  of  the  coronal  pulp,  the  inflammation 
assumes  a  decided  chronic  character  in  the  radical  pulp,  and 
we  find  nothing  but  the  scanty  remains  of  the  latter  in  the  carious 
roots,  though  the  chronic  inflammatory  process  may  have  been 
terminated  for  a  long  time.  Atrophic,  shrivelled,  connective 
tissue  with  a  tinge  of  dirty-yellow  and  brown,  here  and  there, 
presenting  barely  traces  of  net-like  atrophy,  accumulations  of 
crystals  of  heematoidin  and  calcareous  grains  compose  the 
principal  constituents. 

A  chronic  inflammatory  condition  of  the  root-pulp,  in  quite 
rare  cases,  leads  to  a  new-formation  of  bony  substance  or  osteo- 
dentine  upon  the  interior  surface  of  the  root-canal  and  may 
even  give  rise  to  the  development  of  anastomosing,  rapidly  ob- 
literated vascular  canals  which  are  prolonged  from  the  vessels 
of  the  root-pulp  into  the  dentine  and,  in  places,  are  invested  by 
a  layer  of  globular  masses  and  even  by  an  accessory,  well-devel- 
oped bony  substance  with  a  sharply-defined,  indented  border  di- 
rected towards  the  dentine ;   this  substance  occasionally  follows 


CARIES    OF    THE    DIFFERENT    KINDS    OF    TEETH.        893 

the  course  of  the  root-canal,  forming  a  complete  investment 
about  it  (Atlas,  Fig.  98). 

The  periosteum  of  the  root  usually  is  notably  thickened  and 
sclerosed,  and  consequent  upon  this  occur  hypertrophies  and 
interstitial  proliferations  of  the  cement  into  the  dentine.  On 
the  other  hand,  a  marked  resorption  may  occur,  involving  either 
the  entire  cement  or  portions  of  it  and  causing  numerous 
breaches  of  substance  in  the  hypertrophic  cement,  in  consequence 
of  which  the  surface  of  the  carious  root  sometimes  presents  deep 
excavations  and  is  rough  to  the  touch  (comp.  p.  273). 

The  carious  discoloration  of  the  dentine  usually  does  not  ex- 
tend to  a  great  depth  and  the  cartilaginous  softening,  likewise, 
is  moderate  in  amount.  A  discoloration  of  the  cement  is  met 
with  only  in  exceptional  cases  when,  in  consequence  of  resorp- 
tion, it  remains  projecting  from  the  margin  of  the  carious  cavity. 
The  dentinal  substance  within  the  carious  locality  sometimes 
presents  a  gray  cloudiness  from  the  accumulation  of  finely-di- 
vided fat,  which  may  be  demonstrated  by  the  application  of  hy- 
drochloric acid.  Grains  of  leptothrix  occasionally  proliferate 
in  large  numbers  within  the  perforated  dentine. 

Caries  of  the  different  kinds  of  Teeth. — As  a  general 
rule,  caries  originates  in  the  external  depressions  of  the  teeth, 
which  afford  localities  for  the  accumulation  of  foreign  matter, 
the  removal  of  which  is  difficult  or  utterly  impossible.  The 
localities  primarily  affected  comprise  chiefly  the  longitudinal 
and  transverse  grooves  upon  the  masticating  surfaces  of  the 
bicuspids  and  molars,  the  contiguous  surfaces  of  crowded  teeth, 
all  the  deep  and  manifold  indentations  and  grooves  which  occur 
upon  surfaces  that  are  smooth  normally  and  are  occasioned  by 
malformations  of  the  enamel,  and,  finally,  all  surfaces  which  are 
repeatedly  or  constantly  brought  into  contact  with  the  labial  or 
buccal  mucous  membrane  or  the  secretion  of  the  gums,  as  the 
facial  surfaces  of  the  necks  of  the  teeth.  The  surfaces  directed 
towards  the  cavity  of  the  mouth  nearly  always  remain  unaffected 
by  caries,  since  foreign  matters  adhere  to  them  only  with  dif- 
ficulty, being  readily  removed  by  the  movements  of  the  tongue, 
except  in  those  cases  where  there  are  depressions  from  defects 
in  the  enamel.     Caries  seldom  originates  upon  the  contiguous 


394  ANOMALIES    OF    THE    SECRETIONS. 

surfaces  of  teeth  which  are  separated  by  slight  intervals  from 
each  other,  or  stand  alone  in  consequence  of  the  detachment  or 
extraction  of  the  adjacent  teeth. 

Permanent  Teeth, — The  labial  surfaces  of  transversely- 
grooved  upper  central  incisors  are  liable  to  be  attacked.  A 
uniformly  dirty-yellow  spot,  corresponding  to  the  locality  of  the 
transverse  groove,  is  observed  at  first.  If  a  breach  of  substance 
has  occurred,  there  is  found  a  transverse  oval  depression.  If 
the  facial  surfaces,  especially  in  the  lower  segments,  present  a 
number  of  depressions,  these,  particularly  the  larger  ones,  are 
very  liable  to  become  the  seat  of  caries.  The  medial,  contiguous 
surfaces  of  both  teeth,  Avhen  the  crowns  are  closely  approximated 
or  overlap,  are  attacked  in  the  vicinity  of  the  incisive  edges. 
The  lateral  (distal)  surfaces  are  more  frequently  the  subjects  of 
the  disease,  particularly  if  the  lateral  incisor  has  an  oblique 
position  and  the  contact  of  the  surfaces  of  the  lateral  and  cen- 
tral incisors  respectively  is  more  extensive  and  closer  than  is 
the  case  ordinarily.  The  crowns  of  these  teeth,  at  the  carious 
localities,  present  hemispherical  excavations  which,  facing  each 
other,  form  a  roundish  cavity.  The  facial  surfaces  of  the  necks 
of  the  upper  central  incisors  not  infrequently  are  the  seat  of 
extensive  caries.  The  lingual  surfaces  are  affected  only  Avhen 
an  infundibuliform  depression  between  two  folds  of  enamel 
(comp.  p.  33)  or  transversely-disposed  indentations  are  present. 

The  not  infrequently  displaced  and  distorted  upper  lateral 
incisors  are  very  likely  to  become  affected  with  caries,  the 
liability  being  increased  by  the  multiplication  of  the  points  of 
contact  with  the  adjacent  teeth.  The  surfaces  which  come  into 
contact  with  the  contiguous  teeth  or  the  facial  surfaces  of  the 
necks  are  most  frequently  the  seat  of  the  origin  of  caries.  We 
have  also  seen  cases  where  the  disease  arose  in  connection  with 
transverse  grooves  upon  the  facial  surface,  and  with  indentations 
or  an  infundibuliform  depression  upon  the  lingual  surface. 

The  upper  canines  are  affected  primarily  upon  the  facial  sur- 
face of  the  necks  and  less  frequently  upon  the  surfaces  in  rela- 
tion with  the  adjacent  teeth,  which  usually  are  previously 
affected  with  caries ;  the  facial  surfaces  of  the  crowns  are  at- 


CARIES    OP    THE    DIFFERENT    KINDS    OF    TEETH.         395 

tacked  only  when  they  present  depressions  and  grooves  in  the 
enamel.* 

The  upper  bicuspids  are  invaded  in  the  depressions  upon  the 
masticating  surface,  more  frequently  upon  the  surfaces  which 
come  into  contact  with  the  adjacent  teeth,  and  upon  the  buccal 
surfaces  of  the  necks. 

In  the  ji7^8t  upper  molars,  the  disease  very  frequently  makes 
its  appearance  in  the  depressions  formed  by  the  branching 
grooves  and  very  commonly  at  several  points  simultaneously, 
if  the  abnormally  developed  enamel  contains  numerous  depres- 
sions and  grooves.  The  masticating  surfaces  of  the  second  and 
third  molars  are  less  frequently  the  seat  of  primary  caries  than 
those  of  the  first  molars.  The  buccal  surfaces  of  the  wisdom 
teeth,  in  consequence  of  their  close  contact  with  the  mucous 
membrane  of  the  cheeks,  are  quite  liable  to  become  affected. 
Frequently  the  molars  are  attacked  upon  their  surfaces  of  con- 
tact, and  upon  their  necks  when  the  teeth  are  worn  down  upon 
their  masticating  surfaces,  while  there  may  be  no  perceptible 
aff"ection  of  any  other  portion  of  the  crown. 

The  lotver  iiicisors  are  attacked  upon  their  surfaces  of  contact, 
upon  the  surfaces  of  the  necks  and  those  of  the  crowns  presenting 
depressions  in  the  enamel,  and  upon  the  surfaces  of  slightly 
overlapping  and  displaced  teeth,  which  come  into  immediate 
contact. 

The  disease  makes  its  appearance  in  the  lotver  canines,  gener- 
ally in  consequence  of  contact  with  carious  portions  of  adjacent 
teeth,  upon  the  surfaces  of  contact  and  upon  the  fiicial  portions 
of  the  necks. 

The  primary  aff'ection  of  the  lotver  bicuspids  occurs  in  the  de- 
pressions upon  their  summits,  frequently  upon  the  surfaces  of 
contact,  especially  when  there  is  a  displacement,  and  upon  the 
facial  surfaces  of  the  necks. 

The  lower  molars  become  affected  at  the  points  of  intersection 

*  In  this  country,  caries  of  the  upper  canines  occurs  most  frequently  upon 
their  proximate  surfaces,  the  facial  surfaces  of  their  necks  seldom  being  dis- 
eased. In  the  tables  of  Mr.  Tomes,  in  fifty-eight  extractions  of  canines  from 
the  upper  jaw,  nine  were  carious  upon  their  proximate  surfaces  and  but  one 
on  the  facial  surface. — T.  B.  H. 


896  ANOMALIES    OF    THE    SECRETIONS. 

of  the  grooves,  at  the  points  of  divergence  of  the  lateral  grooves, 
frequently  upon  the  surfaces  of  contact  and,  sometimes,  upon 
the  facial  surfaces  of  the  necks.  The  wisdom  teeth,  particularly, 
and  the  first  molars,  in  consequence  of  the  frequent  occurrence 
of  anomalies  in  the  development  of  the  enamel,  are  attacked  in 
more  than  one  place. 

Carious  Roots  of  Permanent  Teeth. — One  would  be  astonished 
at  the  large  number  of  carious  roots  which  may  be  found  by  ex- 
aminations, post  mortem,  a  fact  to  be  accounted  for  by  the  gross 
neglect  of  the  teeth,  particularly  among  the  lower  classes  of  peo- 
ple. The  roots  of  the  molars  rank  first;  these  are  excavated, 
present  sharp  edges  and  points  and,  sometimes,  the  remains  of 
enamel.  In  consequence  of  the  frequent  occurrence  of  alveolar 
abscesses,  the  carious  roots  become  deprived  in  part  of  their 
support,  particularly  upon  the  facial  wall  of  the  upper  jaw,  and 
it  is  not  uncommon  for  them  to  become  twisted  slightly  and  in- 
clined to  a  considerable  degree  towards  the  face;  in  some  cases, 
the  alveoli  are  destroyed  almost  entirely  by  suppuration,  and 
the  roots  occupy  a  nearly  horizontal  position,  attached  to  the 
closed  terminal  portions  of  the  alveoli  by  means  of  the  thickened 
root-membrane.  In  consequence  of  suppuration  of  the  alveoli, 
the  carious  roots  of  the  lower  molars  acquire  a  marked  inclina- 
tion anteriorly. 

Carious  roots  of  teeth  which  have  but  one  root  generally  re- 
tain their  normal  positions,  but  sometimes  acquire  a  fiicial  or 
lingual  inclination,  particularly  if  they  are  employed  in  chewing 
during  the  progress  of  chronic  caries,  which  fact  will  be  indi- 
cated by  the  surfaces,  grooves,  and  step-like  breaks  produced  by 
chewing.  It  is  self-evident  that  abraded  surfaces  of  this  descrip- 
tion can  only  be  produced  when  several  of  the  neighboring  teeth 
are  wanting,  or  merely  their  roots  remain. 

Milk  Teeth. — In  consequence  of  their  less  compact  character 
(Thomson,  of  Glasgow,  found  less  than  thirty-seven  per  cent, 
of  organic  matter  in  the  milk  teeth),  the  thinness  of  their  enamel 
layers  and  the  profuse  secretion  from  the  gums  and  glands  of 
the  oral  cavity,  caries  has  a  more  acute  course  in  the  temporary 
teeth.  The  molars  are  attacked  most  frequently;  their  crowns 
are  destro3^ed  to  a  considerable  extent,  the  carious  cavities  are 


FREQUENCY    OF    CARIES.  397 

comparatively  large  ;  the  dentine  frequently  is  studded  -with 
several  light-brown  spots  ;  a  considerable  portion  of  the  thin 
enamel,  of  the  incisors  especially,  becomes  detached  quite  easily, 
leaving  the  light-brownish  discolored,  and  superficially  softened 
dentine  exposed.  If  the  caries  has  a  very  acute  course,  it  in- 
volves the  entire  circumference  of  the  crown  which,  finally,  is 
destroyed.  The  disease  attacks,  primarily,  the  depressions  and 
grooves  upon  the  masticating  surfaces  of  the  molars,  the  facial 
surfaces  of  the  necks  and  the  surfaces  of  contact  with  adjacent 
teeth.  The  extension  of  the  disease  from  a  carious  tooth  to  its 
sound  neighbor  (infection)  takes  place  quite  rapidly ;  it  is  not 
uncommon  to  fi^nd  most  of  the  teeth  in  a  jaw  affected. 

Frequency  of  Caries. — Magitot*  tabulated  a  series  of  cases, 
ten  thousand  in  number,  showing  the  relative  frequency  of  caries 
in  the  different  kinds  of  permanent  teeth.  Taking  all  the  cases 
into  consideration,  it  appears,  he  says,  that  the  relative  fre- 
quency of  caries  in  the  upper  and  lower  teeth  respectively,  is  in 
the  proportion  of  3  :  2.  This  proportion,  however,  is  not  appli- 
cable to  the  molars,  since  the  first  aud  second  lower  molars  are 
affected  more  frequently  than  the  corresponding  teeth  of  the 
upper  jaAV.  From  his  tables,  however,  this  result  may  be  stated 
more  in  detail,  as  follows  :  The  quotients,  expressing  the  ratio 
of  frequency,  presented  by  the  several  kinds  of  teeth  in  the 
upper  and  lower  jaw  respectively,  are  in  round  numbers,  20  for 
the  central  and  24  for  the  lateral  incisors,  6  for  the  canines,  2.5 
for  the  first,  and  1.6  for  the  second  bicuspids,  0.8  for  the  first, 
0.6  for  the  second,  and  1.5  for  the  third  molars;  that  is  to  say, 
the  upper  central  incisors  are  affected  twenty  times  as  often  as 
the  corresponding  te.eth  of  the  lower  jaw,  and  so  on.  No  im- 
portant difference  is  observed  between  the  teeth  on  the  right 
aRd  left  side  respectively.  According  to  Magitot's  tables,  the 
different  kinds  of  teeth  present  the  following  order,  in  respect 
of  the  frequency  of  their  affection  with  caries,  beginning  with 
those  most  frequently  affected:  lower  first  molar,  upper  first 
molar,  lower  second  molar,  upper  first  bicuspid,  upper  second 
bicuspid,  upper  lateral  incisor,  upper  second  molar,  upper  cen- 

*  Op.  cit.,  p.  48. 


398 


ANOMALIES    OF    THE    SECRETIONS. 


tral  incisor,  lower  second  bicuspid,  upper  canine,  lower  first 
bicuspid,  upper  Avisdom  tooth,  lower  wisdom  tooth,  tlie  two  loAver 
incisors.  The  scale  drawn  up  by  Hasler  Harris*  corresponds 
very  nearly  with  this.f 


*  Quart.  .Jour,  of  Dental  Science,  1857. 

•j-  The  following  is  the  table  by  Dr.  E.  Magitot,  referred  to  in  the  text : 


Central  Incisors,       .     .     .  642 

Lateral  Incisors,       .     .     .  777 

Canines, 515 

1st  Bicuspids, 1,310 

2d  Bicuspids, 1,310 

1st  Molars, 3,350 

2d  Molars, 1,736 

3d  Molars, 360 


Superior, 
Inferior, 
Superior, 
Inferior, 
Superior, 
Inferior, 
f  Superior, 
(  Inferior, 
Superior, 
Inferior, 
Superior, 
Inferior, 

{Superior, 
Inferior, 
Superior, 
Inferior, 


Total,  , 

Superior, 
Inferior, 


10,000 


6004 
3996 


61 


H 


30 


Eight, 
Left,  . 
r  Riirht, 


\  Left,  . 

«o  { s:: 

445  i  ^'"^*' 
^*^  I  Left,  . 

.„  r  Right, 

'      t  Left,  . 
r  Right, 


ro 


940 


\  Left, 

«™  { ft: 


500 


f  Right, 


\  Left,  . 
1  ci'A    r  Bight, 
'  (^  Left,  . 

,,810  {E.f; 

1  046  /  ^''^'^^*' 
^'^^^    I  Left,  . 

990  /  K'2;ht, 
'^"^  \  Lett,  . 


10,000 


Right  side  face, 
Lett,     "       " 


4791 
5209 


304 

308 

20 

10 

369 

378 

20 

10 

198 

247 

20 

50 

345 

595 

170 

200 

400 

410 

270 

230 

728 

812 

910 

900 

380 

310 

497 

549 

100 

120 

60 

80 


10,000 


This  table  differs  in  several  respects  from  one  prepared  by  me,  from  records 
of  tilling  and  extractions  of  permament  teeth  in  twenty  thousand  cases. 
Though  this  includes  extractions  from  all  causes,  yet  the  percentage  removed 
for  other  diseases  than  caries  is  so  small,  that  the  tables  are  worthy  of  com- 
parison. T.  B.  H. 


FREQUENCY    OF    CARIES. 


399 


With  regard  to  the  sex,  according  to  Magitot's  enumeration, 
the  ratio  of  3  :  2  expresses  the  relative  frequency  of  caries  of  the 
teeth  in  females  as  compared  with  the  same  in  males.  Harris 
asserts  that  with  females  caries  occurs  nearly  three  times  as 
often  as  it  does  with  males.  The  period  of  pregnancy,  as  is 
well  known,  is  especially  favorable  to  the  development  of  caries. 

With  regard  to  the  age,  caries  is  most  frequent  between  the 
tenth  and  twentieth  year  of  life.  Later  in  life  (about  the  fiftieth 
year),  it  is  not  uncommon  for  another  period  to  occur  in  which 
teeth,  previously  sound,  are  destroyed  by  caries  within  a  short 
time.  Magitot  drew  up  some  instructive  tables  in  detail,  show- 
ing the  age  at  which  the  several  corresponding  teeth  in  both 
jaws  were  affected.     With  regard  to  the  milk  teeth,  he  ascer- 


Central  Incisors,   . 

(  Superior,  , 
.     2,189  \ 

(  Inferior,    . 

2,101  {£?;;'. ; 

oo  /  Right,  . 

^^  i  Left,      . 

.    1,058 

1,043 

37 

51 

C  Superior,   . 

J  g.,-  r  Right,  . 

^'^-'   iLeft,      . 

,^-    f  Right,   . 

•        ^-^  \Left,      . 

.       939 

888 

Lateral  Incisors,   . 

.     .     1,954  } 

{  Inferior,    . 

G8 
59 

Canines,  .... 

C  Superior,   . 
.     1,261  J 

(  Inferior,    . 

1,058  {  Egl.'.  . 

.       504 
554 
101 

.       102 

(  Superior,  . 

7G7 
821 

1st  Bicuspids,    . 

.     2,073 

(.  Inferior,    . 

264 
221 

2d  Biscuspids,  .     . 

("Superior,  . 
.     2,585  \ 

[  Inferior,    . 

1  71'%  /^'-l>^'    • 
^'^l''  1  Left,      . 

„.^  ;  Riglit,   . 

^'^1  Left,      . 

906 
809 
467 
403 

1st  Molars,  .     .     . 

C  Superior,  . 
.     4,499  ] 

[  Inferior,    . 

2  97':!  i  P^'S-ht,   . 
^'-"^   1  Left,       . 

0  1  Ofi   r  Right,  .    . 

-''-'''  iLeft,      .     . 

1,189 

1,084 
1,092 
1,034 

2d  Molars,    .     .     . 

f  Superior,  . 
.     3,615  } 

[  Inferior,   . 

■.«MS;'': 

838 

837 

938 

1,002 

3d  Molars,    .     .     . 

C  Superior,  . 
.     1,924  \ 

(Inferior,   .     . 

470 

429 

513 
512 

Total,     .     . 

.     20,000 

20,000 

20,000 

Superior, 

.     13,1.36       f      Right  sid 
6,864     t      Left      " 

e  face,     .     .     10,151 

Inferior, 

.     .       9,849 

400  ANOMALIES    OF    THE    SECRETIONS. 

tained  that  caries  may  be  observed  as  early  as  the  third  and 
fourth  year,  and  that  its  frequency  increases  in  regular  progres- 
sion from  this  period  up  to  the  twelfth  year,  the  period  at  which, 
on  the  average,  the  last  milk  tooth  becomes  detached. 

In  respect  of  7'ace,  notable  diiferences  are  observed.  Broca, 
and  more  particularly  Mummery,  carefully  examined  large  col- 
lections of  skulls,  for  the  purpose  of  ascertaining  the  frequency 
of  dental  caries.  The  latter  found  a  percentage  of  41.66  as  ex- 
pressing the  frequency  of  caries  among  those  of  the  ancient 
Egyptians,  2.94  among  those  of  the  ancient  Britons  with  elon- 
gated skulls,  21.87  among  those  with  round  skulls,  28.67  among 
those  of  the  Romano-Britons,  15.78  among  those  of  the  Anglo- 
Saxons.  Among  the  modern  races,  he  obtained  the  lowest  per- 
centage from  those  of  the  Esquimaux,  natives  of  the  northern 
coasts  of  America,  New  Zealanders,  and  inhabitants  of  the 
northern  parts  of  the  East  Indies.  In  Europe,  the  results  show 
a  percentage  in  favor  of  the  Sclavonic  race. 

In  connection  with  the  peculiarities  in  the  structure  of  the 
teeth  according  to  race  may  be  considered  those  which  are 
manifested  according  to  family.  It  is  a  familiar  fact  to  all 
dentists,  that  children's  teeth  very  frequently  resemble  those  of 
the  father  or  mother  and,  therefore,  that  many  defects  and  mal- 
formations of  the  teeth  are  hereditary  in  a  family,  e.  g.^  the  ab- 
sence of  the  upper  lateral  incisor,  the  oblique  position  of  a  certain 
tooth,  the  shape  of  the  teeth,  spots  upon  them,  &c.  In  the  same 
way,  also,  is  the  familiar  and  curious  fact  to  be  explained,  that 
with  children  of  the  same  family  the  corresponding  teeth  become 
carious  in  the  same  order,  at  similar  points  and  at  a  certain  age. 

Many  are  inclined  to  ascribe  the  differences  in  respect  of  the 
frequency  of  caries,  to  locality  and  the  articles  of  diet.  Climatic 
and  geological  peculiarities,  or  the  Avater,  are  assigned  as  the 
causes,  though  authoritative  grounds  cannot  be  adduced  in  sup- 
port of  these  views.  Mummery  endeavored  to  establish  a  par- 
allel between  the  ordinary  food  of  the  different  races  and  the  per- 
centage illustrating  the  frecjuency  of  caries,  but  definite  results 
cannot  be  drawn  from  these  data.  As  a  matter  of  course,  ade- 
quate nutritive  material  is  just  as  requisite  for  the  formation 
and  maintenance  of  the  teeth  as  it  is  for  the  rest  of  the  body, 


FREQUENCY    OF    CARIES.  401 

whether  it  be  of  an  animal  or  vegetable  nature.  If  it  be  true 
that  geological  and  climatic  conditions,  and  the  means  of  sub- 
sistence Avhich  are  connected  with  the  same,  have  such  a  pre- 
ponderating influence  in  respect  of  the  frequency  of  caries,  then 
it  is  impossible  to  explain  the  fact  that  foreigners  belonging  to 
different  races,  who  are  exposed  to  the  same  conditions  with  the 
native  inhabitants,  still  retain  the  typical  structure  of  their  teeth 
as  well  as  that  of  their  bodies,  and  continue  to  furnish  the  pro- 
portion of  dental  caries  peculiar  to  their  race.  This  is  found  to 
be  the  case  with  the  isolated  Sclavonic  races  of  Austria  and  the 
descendants  of  the  Celtic  race  in  France.* 

Popular  customs  promote  or  retard  and  may  even  give  rise 
to  caries.  Steinbergerf  remarks,  in  this  connection,  that  the 
crowns  of  the  upper  milk  incisors,  especially  in  children  of  the 
lower  classes,  are  mostly  or  entirely  destroyed  by  caries  even 
in  the  second  or  third  year  of  life,  while  the  lower  incisors  are 
scarcely  ever  so  extensively  affected  and  the  molars,  usually,  are 
still  entirely  sound.  It  is  found  in  such  cases  that  the  children 
have  been  accustomed  for  months  and  even  years  to  use  a  suck- 
ing-bag containing  cracker  or  white  bread  which  is  first  soaked 
in  milk  and  then  in  a  weak  solution  of  sugar.  In  this  way,  he 
says,  all  the  conditions  necessary  for  the  rapid  formation  of 
vinegar  are  afforded ;  the  sugar  acts  during  the  process  of  its 
fermentation,  and  the  action  of  acid  in  statu  nascenti  is  much 
more  intense. 

Tobacco-smoke  or  juice  is  considered  by  many  to  be  a  pre- 
servative, or  a  means  of  preventing  caries,  though  it  is  not  stated 
whether  the  secretion  of  the  gums  acquires  an  alkaline  condition 
or  the  proliferation  of  leptothrix  is  diminished.  On  the  other 
hand,  it  is  quite  common  to  find  teeth  with  a  sooty  covering, 

*  As  geological,  climatic,  and  social  conditions  exercise  a  predominant 
influence  upon  the  growth  and  development  of  the  A'arious  races  mentally 
as  well  as  physically,  it  is  evident  that  the  development  of  the  dental  organs 
cannot  fail  to  be  controlled  by  the  same  causes.  In  this  country,  which  is 
annually  receiving  large  numbers  of  foreigners  by  emigration,  the  typical 
traces  of  race  are  usually  effaced  after  the  lapse  of  a  generation  or  two,  the 
descendants  possessing  all  the  peculiarities,  and  their  teeth  apparently  being 
as  liable  to  caries  as  the  teeth  of  Americans  generally. — T.  B.  H. 

t  Deutsche  Viertelj.  f.  Zahnh.,  1862. 

26 


402  ANOMALIES    OP    THE    SECRETIONS. 

from  tobacco-smoke,  upon  the  lingual  surface  and,  at  the  same 
time,  an  extensive  carious  affection  of  the  facial  surface  of  the 
neck. 

An  enumeration  has  been  made  of  the  articles  of  diet  -svhich 
are  said  to  tend  to  increase  the  frequency  of  caries,  such  as 
fruit,  food  which  has  become  sour,  curdled  milk ;  but  sugar  is 
regarded  as  the  most  injurious.  Larrey*  asserted  that  teeth 
are  acted  upon  by  a  solution  of  sugar,  the  enamel  acquiring  an 
opaque  appearance,  the  tooth  readily  crumbling  and  becoming 
almost  gelatinous.  In  this  connection,  stress  is  laid  upon  the 
affinity  of  the  sugar  for  the  lime  with  which  it  enters  into  com- 
bination. Marchand  denied  the  accuracy  of  these  experiments, 
and  asserted  that  no  perceptible  changes  can  be  detected  in 
teeth  which  have  lain  for  weeks  in  a  solution  of  sugar.  It  has 
also  been  stated  by  English  writers  that  the  natives  of  the  East 
Indies  eat  a  large  amount  of  sugar  and  with  a  mere  vegetable 
diet  have  very  good  teeth  ;  to  be  sure,  they  keep  their  teeth 
very  clean.  Magitot  recently  experimented  with  sugar  and  ob- 
tained a  result  corresponding  with  that  of  A.  Westcott  (1843), 
namely,  that  sugar  exercises  no  direct,  i.  e.,  in  the  condition  of 
sugar,  injurious  effect  upon  the  teeth,  since  solutions  of  sugar 
occasioned  extensive  destruction  of  the  tooth  only  after  some 
time  (two  years)  had  elapsed,  when  the  solutions  were  left  alone 
or  materials  were  added  to  them  which  acted  the  part  of  ferments. 
The  fermentative  process  gives  rise  to  the  development  of  lactic 
acid  and,  subsequently,  butyric  acid  and  a  few  of  its  derivatives, 
as  propionic  and  valeric  acids,  &c.  Mantegazza,  of  Pavia,  ex- 
perimented in  another  way ;  he  placed  teeth,  which  had  pre- 
viously been  dried  and  weighed,  in  solutions  of  sugar  of  various 
degrees  of  concentration,  in  distilled  Avater  and  in  saliva  which 
was  removed  directly  from  the  mouth,  and,  after  a  few  days, 
noticed  an  acid  reaction  of  the  fluid  which  contained  traces  of 
lime ;  the  teeth  had  lost  in  weight.  His  conclusions  coincide 
pretty  nearly  with  those  of  Magitot. 

Various  occupations  are  directly  or  indirectly  injurious.  It 
is  a  well-known  fact  that  the  teeth  of  confectioners  and  cooks 

*  Gaz.  Med.  di  Milano,  1844. 


EFFECTS    OF    CARIOUS    TEETH    ON    THE    BODY.  403 

are  very  apt  to  be  aiFectecl,  and  it  is  supposed  that  the  dust  from 
the  sugar  enters  into  combination  with  the  mucus  of  the  gums 
and  the  deposits  on  the  teeth,  and  occasions  an  acid  fermentation. 
Richardson  calls  attention,  in  his  lectures,  to  the  fact  that  dental 
caries  is  exceedingly  common  among  the  fur-dyers,  since  the 
teeth  are  acted  upon  by  the  fumes  of  the  nitric  acid  which  is 
employed  for  cleansing  and  imparting  a  yellow  color  to  the  furs. 
The  fumes  produce  a  dryness  and  irritated  condition  of  the  oral 
mucous  membrane  of  the  tongue  and  fauces ;  as  a  rule  there  is 
constipation,  pain  in  the  occipital  region  and  a  sensation  of 
constriction  of  the  chest.  The  drying-room,  in  which  are  placed 
the  damp  skins  impregnated  with  the  nitric  acid,  is  filled  with 
the  fumes  of  this  acid.  The  teeth  lose  their  enamel  and,  occa- 
sionally, are  entirely  destroyed.  The  fumes  of  ammonia,  also, 
and  the  dust  occasioned  by  beating  the  dried  skins,  exercise  an 
injurious  action.     • 

.  Many  diseases  of  the  general  system  promote  the  development 
of  caries,  especially  those  during  the  existence  of  which  the 
mixed  saliva  generally  acquires  an  acid  reaction,  including 
many  forms  of  dyspepsia,  cancer  of  the  stomach,  diabetes, 
scrofula,  rachitis,  phthisis,  and  aphthae. 

Effects  of  Carious  Teeth  upon  the  Rest  of  the  Body. — 
Although,  in  many  cases,  it  is  hardly  possible  to  decide  abso- 
lutely whether  the  caries  is  the  result  or  the  cause  of  a  certain 
affection,  still  approximate  results  may  be  obtained  from  the 
observation  of  cases  in  which  a  healthy  condition  is  restored 
after  the  removal  of  carious  teeth.  Every  dentist  has  oppor- 
tunities enough  for  observing  cases  of  this  kind. 

The  effects  are  manifested  in  adjacent  or  more  distant  organs 
with  which  the  mixed  saliva  comes  into  contact.  The  sharp 
edges  of  carious  teeth  sometimes  give  rise  to  ulcerations  having 
a  cancerous  appearance  upon  the  oral  mucous  membrane,  the 
tongue,  or  lips,  a  fact  readily  explained  since  the  wounded  parts 
are  constantly  exposed  to  the  foul  products  of  decomposition, 
resulting  from  the  carious  disease.  Listen  ascribed  a  number 
of  local  and  general  affections  to  the  presence  of  carious  teeth 
or  decomposed  fragments  of  teeth.  The  consecutive  inflamma- 
tions of  the  pulp,  root-membrane,  gums  and  periosteum,  the  ab- 


404 


ANOMALIES    OF    THE    SECRETIONS. 


scesses  in  the  alveoli  and  jaws,  have  been  considered  in  the  pre- 
ceding pages.  Listen  also  considers  caries  of  the  teeth  to  be  a 
frequent  cause  of  swelling  of  the  tonsils,  intense  and  long-con- 
tinued headache,  various  digestive  derangements  and  gastralgias, 
which  affections  disappear  as  soon  as  the  offending  carious  teeth 
are  removed. 

Caries  of  Reinserted  Human  Teeth. — As  a  rule,  the 
necks  of  these,  and  especially  of  the  front  teeth  of  the  upper 
jaw,  become  the  seat  of  the  disease  which  generally  affects  their 
entire  circumference.  This  fact  is  easily  explained  when  we 
consider  that  the  gum  does  not  become  attached  to  the  neck, 
and  hence  accumulations  of  the  secretions  occur  more  readily. 
The  dentine  in  the  above  locality  acquires  a  dirty-j^ellow, 
brownish- yellow,  dirty-brown  discoloration  and  undergoes  a 
superficial  cartilaginous  softening  which  spreads  beneath  the 
enamel-layer  adjacent  to  the  neck,  and  the  enamel  acquires  an 
eroded  appearance. 

The  deposits  of  pigment,  consequent  upon  the  carious  pro- 
cess, may  be  traced  to  a  depth  of 
1  to  2  millimetres  into  the  dentine; 
s_-^!^?f  adjacent  to  the  pigmented  portion 
occurs  a  dark  zone  which  adjoins 
another,  in  many  cases,  very  light 
zone.  Upon  close  examination  of 
the  dark  zone  and  its  transition  into 
the  pigmental  and  light  portions, 
respectively,  the  same  changes  are 
found  as  in  ordinary  caries  of  the 
teeth.  The  canals  are  filled  with 
rows  of  minute  grains  which  gen- 
erally have   a   roundish,   in    some 


Fig.  101/ 


*  Fig.  101  illustrates  a  carious  affection  of  the  dentine  of  a  reinserted 
human  incisor.  The  portion  of  dentine  examined  still  retained  sufficient 
consistence  to  allow  a  thin  and  polished  section  to  be  prepared.  At  the  upper 
surface  (a)  are  sharply  defined  cavities ;  these  were  filled  with  masses  of  lep- 
tothrix  which  have  fallen  out.  Next  in  order  is  a  granular,  cloudy  portion 
where  the  canals,  which  are  more  clearly  visible  beyond  (b),  are  filled  with 
grains  arranged  in  rows  like  strings  of  pearls.  The  interglobular  spaces  (c) 
are  clouded  by  accumulations  of  dirty-brownish  molecules.  Magnified  500 
diameters. 


CARIES    OF    REINSERTED    HUMAN    TEETH. 


405 


cases,  an  elongated,  rod-like  shape,  are  very  clearly  distinguish- 
able from  the  intermediate  substance  and,  when  they  are  of 
larger  size,  form  chains  like  strings  of  pearls  (Fig.  101).  If  the 
calcareous  salts  be  removed  from  dentine  of  this  description,  by 
means  of  hydrochloric  acid,  and  heat  be  applied  until  the  pro- 
cesses of  the  dentinal  cells  are  set  free,  knotty  swellings  make 
their  appearance  upon  them,  in  precisely  the  same  manner  as  in 
ordinary  carious  dentine.  The  processes,  here  and  there,  are 
beset  with  grains  of  leptothrix  ;  quite  a  large  portion  of  the 
granular  mass  in  the  canals  and  clouded  intertubular  tissue,  how- 
ever, is  composed  of  fat,  as  is  shown  by  the  fact  that  it  forms  a 
large  number  of  drops  on  the  addition  of  hydrochloric  acid. 
The  interglobular  masses  are  light  in  some  places ;  in  others  they 
present  a  molecular  cloudiness  and,  sometimes,  a  dirty-brownish 
discoloration. 

The  outer  surface  of  the  Softened,  cartilaginous  dentine  pre- 
sents very  distinct  perforations  which  ex- 
tend to  a  considerable  depth  into  its  sub- 
stance. These  form  the  chief  abode  of 
the  masses  of  leptothrix  which  occupy 
the  manifold  excavations  and  may  be 
traced  in  the  irregular  pouches  which 
dip  down  deeply  along  the  course  of  the 
dentinal  canals  (Fig.  102).  The  den- 
tinal fibres,  beset  with  an  abundance  of 
grains  of  leptothrix,  form  free  projections 
beyond  the  borders  of  the  section,  when 
there  is  a  marked  degree  of  cartilaginous 
softening,  and  in  cross-sections  display, 
here  and  there,  a  notable  thickening.  A 
violet  color  may  readily  be  imparted  to  the 
leptothrix  mass  by  means  of  iodine  and 
hydrochloric  acid. 


*  Fig.  102  shows  softened,  cartilaginous,  carious  dentine,  from  a  reinserted 
human  tooth.  Proliferations  of  leptothrix-matrix  have  taken  place  from 
irregular,  pouch-like  excavations  into  the  dentine,  along  the  course  of  the 
canals.     Maa:nified  500  diameters. 


406  ANOMALIES    OF    THE    SECRETIONS. 

In  addition  to  the  above,  mycelium  tubes,  similar  to  those  of 
oidium  albicans,  are  met  with,  sometimes,  upon  the  surface  of 
the  decomposed  dentine. 

Caries,  as  is  well  known,  frequently  makes  rapid  progress  in 
the  dentine  of  reinserted  teeth.  I  observed  a  case  where,  in 
fourteen  days  after  the  insertion  of  a  pivoted  tooth,  the  dentine 
in  the  vicinity  of  the  pivot  was  found  to  have  acquired  a  deep 
black  color,  to  the  depth  of  about  one-third  of  a  millimetre. 
Brown  and  light  spots  pervaded  the  dentine. 

The  eroded  border  of  the  enamel  presents  cup-shaped  exca- 
vations and  numerous  cracks  which  extend  in  short  segments 
along  the  undulatory  courses  of  the  enamel  fibres,  or  form  a 
network.  In  the  vicinity  of  the  affected  portions,  the  enamel 
has  a  mottled,  clouded  appearance,  the  prisms  have  a  dark  or 
black-brown  color,  with  a  reddish  tinge,  now  and  then,  and  are 
in  the  process  of  disintegration. 

Caries  of  Teeth  made  of  Ivory  from  the  Hippopotamus. 
— Thomson  calculated  the  specific  gravity  of  this  ivory  to  be 
1.866,  and  the  amount  of  its  organic  substance  to  be  33.41  per 
cent.  The  caries,  which  frequently  is  very  extensive,  does  not 
confine  itself  to  the  artificial  teeth,  but  spreads  beyond  the 
groove  which  serves  for  the  reception  of  the  alveolar  arch.  The 
discolorations  are  very  marked,  being  sometimes  light-colored, 
at  other  times,  dark-brown  ;  the  cartilaginous  softening  is  so 
extensive  that  sections  may  readily  be  made.  The  loss  of  sub- 
stance may  be  quite  considerable,  both  upon  the  necks  and  lat- 
eral portions  of  the  crowns,  and  hemispherical  defects,  sometimes, 
are  formed  upon  adjacent  teeth,  in  the  same  manner  as  in  natural 
teeth ;  it  is  obvious,  therefore,  that  the  carious  process  spreads 
from  one  artificial  tooth  to  its  neighbor.  Caries  generally  com- 
mences upon  the  facial  and  lingual  surfaces,  and  upon  the  mo- 
lars ;  it  originates  in  the  grooves  where  it  forms  irregular  exca- 
vations and,  also,  in  the  vicinity  of  cracks  in  the  dentine  and 
about  those  portions  Avhere  pivots  have  been  inserted,  or  plates 
have  been  adapted. 

The  yellow,  light,  or  dark-brown  pigmental  degeneration  com- 
mences upon  the  carious  surface  and  extends  into  the  dentine  to 
a  depth  of  a  few  millimetres.     Next  to  this  portion  arc  dark 


EXPERIMENTS  UPON  TEETH.  407 

and  light  zones  and,  beyond  the  hitter,  the  contents  of  the  den- 
tinal canals  present  transverse  breaks,  in  many  places.  Some- 
times the  dentinal  fibres  or  processes  of  the  dentinal  cells  dis- 
play such  uniform  transverse  fissures  that  one  might  imagine 
them  to  be  thallus-threads,  composed  of  minute  articulations ; 
in  other  places,  however,  the  irregularity  of  the  clefts  does  not 
admit  of  such  an  interpretation.  The  manner  in  which  the  met- 
amorphosis in  the  dentinal  canals  within  the  dark  and  pigmental 
zone  takes  place  is  quite  evident.  Minute,  sometimes  glittering 
grains,  arranged  closely  together  in  rows  and  following  the  di- 
rection of  the  canals,  and,  towards  the  outer  surface,  rod-like 
bodies,  isomorphous  with  Bacteria,  are  inclosed  in  the  canals. 
Sections,  which  have  been  decalcified  and  heated  until  the  isola- 
tion of  the  dentinal  fibres  has  been  effected,  establish  the  fact 
beyond  any  doubt  that  a  fatty  degeneration  has  ensued  in  the 
affected  dentine  and  that  a  proliferation  of  leptothrix  has  taken 
place  within  the  canals.  The  dentinal  fibres,  frequently  thick- 
ened to  five  and  ten  times  their  normal  size  and  presenting 
varicous  swellings,  are  beset  with  grains  of  leptothrix.  A  violet 
color  is  produced  by  the  latter  in  the  dentinal  canals,  on  the 
addition  of  iodine  and  acid  to  thin  sections. 

Sections  of  the  softened,  cartilaginous  dentine,  made  in  a  di- 
rection perpendicular  to  that  of  the  canals,  present  appearances 
exactly  similar  to  those  found  in  carious  reinserted  human  teeth 
or  in  ordinary  caries  of  normal  teeth,  i.  e.,  we  find,  besides  the 
normal  canals  which  are  considerably  thickened,  have  a  glitter- 
ing appearance  and  are  surrounded  by  a  light  halo,  groups  of 
others,  inclosing,  sometimes,  a  finely-granular  mass,  the  con- 
tents of  which  assume  a  more  or  less  distinct  violet  color  on  the 
addition  of  a  solution  of  iodine  and  acids. 

In  artificial  teeth  in  which  the  dentinal  canals  have  a  direction 
parallel  to  that  of  the  carious  surface,  caries  extends  into  the 
substance,  independent  of  the  course  of  the  dentinal  canals. 

Experiments  upon  the  Teeth  -with  various  Substances. 
— A.  Westcott  (1843)  and  Allport  (1858)  made  special  investi- 
gations in  order  to  determine  the  effects  of  acids  and  other  sub- 
stances upon  the  teeth.  Their  results  coincided  in  showing  that 
mineral  and  vegetable  acids  affect  the  enamel  in  such  a  way  that 


408  ANOMALIES    OF    THE    SECRETIONS. 

it  may  easily  be  scraped  off.  The  former,  also,  ascertained  that 
salts,  whose  acids  have  a  stronger  affinity  for  lime  than  for  their 
own  bases,  likewise  act  upon  the  teeth  ;  that  vegetable  substances 
only  act  when  they  undergo  acetous  fermentation,  as  sugar,  for 
example,  and  that  the  action  of  animal  substances  is  very  slow, 
if,  indeed,  they  exert  any  action,  even  in  association  with  very 
advanced  decomposition.* 

Magitot  submitted  teeth  to  the  action  of  acids,  salts  and  al- 
bumen, during  certain,  quite  long  intervals  (up  to  two  years), 
and  asserts  that  he  produced  conditions  analogous  to  caries. 
He  obtained  positive  results  Avith  lactic  acid  in  the  proportion  of 
1  :  100  parts  of  water.  The  teeth  were  alloAved  to  remain  in  this 
fluid  for  two  years,  when  it  was  found  that  their  roots  had 
become  flexible,  gelatinous,  as  it  were,  and  shorter ;  the  enamel 
was  chalky,  friable,  separated  from  the  coronal  surface  in  places 
and  readi-ly  reducible  to  a  Avhite  powder  by  trituration.  The 
whole  dental  mass  presented  a  general  brownish  color.  Teeth 
which  were  covered  with  resin,  with  the  exception  of  one  portion, 
became  affected  with  penetrating  caries,  in  some  cases  to  a  depth 
of  3  to  4  millimetres.  A  solution  com]30sed  of  a  gramme  of  lactic 
acid  to  a  litre  of  w'ater  made  no  perceptible  effect  upon  teeth 
which  were  kept  immersed  in  it  for  two  years. 

According  to  his  experiments,  butyric  acid  produces  very 
nearly  the  same  effects  as  lactic  acid  ;  the  color  produced  by 
the  caries,  also,  is  analogous.  It  is  a  fixed  acid  not  susceptible 
of  fermentation. 

With  citric  acid,  also,  there  was  no  indication  of  fermentation, 
and  he  found  its  deleterious  action  to  be  quite  intense,  so  that, 
at  the  expiration  of  two  months,  it  was  quite  marked  even  with 
a  solution  of  1 :  1000  parts  of  water.  He  states  that  this  acid 
is  more  injurious  than  any  others  which  act  upon  the  teeth.  It 
occasions  no  discoloration,  which  leads  to  the  conclusion  that  it 
naturally  induces  a  white  caries. 

From  experiments  with  malic  acid  and  cider,  he  found  that 
the  former,  in  the  proportion  of  1 :  100  parts  of  water,  acts  with 
more  energy  than  the  latter. 

*  Leber  und  Rottenstein  iiber  Caries,  p.  68. 


EXPERIMENTS  UPON  TEETH.  409 

Magitot  repeated  the  experiments  of  Berzelius  and  Dumas,  of 
decalcifying  teeth  by  subjecting  them  to  the  action  of  carbonic 
acid,  as  it  occurs  in  Seltzer  water  which,  usually,  contains  one 
volume  of  water  to  five  volumes  of  gas.  The  enamel  became 
friable,  the  dentine  became  softened.  When  equal -volumes  of 
water  and  gas  were  employed,  he  was  unable  to  detect  any 
chanoje  in  the  teeth  which  were  immersed  in  the  solution  durinof 
eight  days.  For  reasons  which  may  readily  be  understood,  he 
is  of  the  opinion  that  acidulated  waters  do  not  act  upon  the 
teeth. 

Teeth  which  were  allowed  to  remain  in  fluid  containing /er- 
menting  alhuminoid  substances  acquired  a  general  and  uni- 
formly softened  condition  in  the  course  of  two  3^ ears  ;  the  roots 
became  transparent  and  soft,  the  enamel  friable  and  opaque. 
Teeth  which  were  protected  entirely,  excepting  at  one  point, 
presented  the  characters  of  true  caries  at  the  exposed  part. 
During  the  putrefaction,  fatty  acids  formed,  of  the  acetic  and 
benzoic  series  ;  the  putrid  odor  suggested  butyric  and  valerianic 
acids. 

A  solution  of  alum  (1 :  100  parts  of  water),  which  at  the 
end  of  two  years  had  an  acid  reaction,  had  not  affected  the  roots 
in  the  least  during  this  period,  while  the  enamel  lost  its  glazed 
appearance,  became  opaque  and  had  the  appearance  and  brittle- 
ness  of  a  layer  of  chalk  ;  the  dentine  and  the  cement  were  not 
in  the  least  affected. 

The  action  of  a  solution  of  hinoxalate  of  potash  (1 :  100  parts 
of  water)  was  very  similar  to  that  of  the  solution  of  alum,  that 
is,  it  was  limited  to  the  enamel. 

Acetic  acid  (1  :  100  parts  of  water)  induced  a  very  peculiar 
change  in  teeth  which  were  allowed  to  remain  in  it  for  two  years. 
The  roots  became  softened  throughout,  flexible,  yellowish  and 
considerably  thinner,  while  the  coronal  portions  remained  unaf- 
fected. The  enamel  retained  its  polished  appearance  and  firm- 
ness. 

Tartrate  and  hitartrate  of  potash  (1 :  100  parts  of  water),  also, 
left  the  enamel  intact  and  attacked  the  cement  and  dentine,  but 
their  action  penetrated  to  a  less  depth  than  that  of  acetic  acid. 

A  solution  of  chloride  of  sodium  (1  :  100  parts  of  water),  con- 


410  ANOMALIES    OF    THE    SECRETIONS. 

taining  a  few  drops  of  creasote,  manifested  no  action  upon  the 
teeth. 

Tannin  (1:100  parts  of  water)  acted  upon  the  cement  and 
dentine,  but  not  in  the  least  upon  the  enamel. 

Magitot  divided  the  substances,  according  to  his  experiments, 
into  four  groups :  1.  Those  which  attack  all  the  dental  sub- 
stances ;  2.  Those  which  occasion  a  disorganization  of  the  enamel 
exclusively  ;  3.  Those  which  act  exclusively  upon  the  dentine 
and  cement ;  4.  Those  which  induce  no  change  in  either  of  the 
three  dental  tissues. 

Unfortunately,  Magitot  neglected  to  make  histological  exam- 
inations of  the  teeth  in  which  caries  was  induced  artificially,  as 
this  would  be  necessary  in  order  to  establish  the  identity  between 
natural  and  artificial  caries, 

Leber  and  Rottenstein  repeated  a  number  of  Magitot's  ex- 
periments, with  these  modifications,  however,  that  they  dimin- 
ished the  duration  of  the  action  and,  as  it  appears,  allowed  the 
substances  to  act  only  upon  the  entire  surfaces  of  the  teeth  and 
not  upon  separate  portions.  They  took  exception  to  the  ex- 
periments of  Magitot  and  showed  that  the  results  are  not  due 
to  the  acids  alone,  but,  also,  to  the  decomposition  of  the  organic 
substance  of  the  tooth,  to  putrefaction  and  fermentation,  and 
that  the  effects  produced  by  the  low  vegetable  and  animal  organ- 
isms which  are  developed  in  the  latter  processes,  also,  are  to  be 
taken  into  account.  They  were  unable  to  satisfy  themselves 
that  the  mere  action  of  acids  produces  changes  exactly  similar  to 
those  observed  in  caries.  Their  experiments  with  tartaric  and 
acetic  acids,  oxalic  acid  and  alum  gave  results  different  from 
those  reported  by  Magitot  in  regard  to  the  non- affection  of  the 
enamel  and  cement  respectively. 

Caries  of  the  Teeth  of  Animals. — I  have  had  an  oppor- 
tunity of  examining  only  a  few  carious  teeth  from  the  horse, 
which  were  furnished  to  me  by  Prof.  F.  Miiller.  As  is  Avell 
known,  caries  of  the  teeth  is  a  very  rare  occurrence  Avith  ani- 
mals. They  were  cases  of  so-called  dry,  chronic  caries,  with  no 
evident,  separable,  cartilage-like,  softened  layers  in  the  dentine 
or  cement. 

In  one  premolar,  the  carious  affection  was  presented  in  its 


CARIES    OP    THE    TEETH    OP    ANIMALS.  411 

early  stage,  in  the  form  of  a  blackish-brown,  circumscribed  spot, 
tlie  size  of  a  lentil,  upon  the  much  worn,  excavated,  grinding 
surface,  and  made  its  first  appearance  on  the  prominent  fold  of 
enamel.  The  carious  pigmental  degeneration  extended,  in  many 
places,  through  the  entire  thickness  of  the  enamel,  as  far  as  the 
line  of  junction  with  the  dentine,  and,  in  well-marked  localities, 
was  indicated  by  an  intense  sap-brown  color,  the  line  of  demar- 
cation being  well  defined.  The  enamel  prisms  appeared  to  be 
filled  with  a  molecular  mass  which  I  did  not  consider  to  be  lep- 
tothrix,  since  the  surface  of  the  enamel  was  found  to  be  smooth, 
and  without  any  deposit  upon  it. 

Where  the  caries  was  more  extensive,  in  the  tray-shaped 
abraded,  grinding  surface,  and  involved,  also,  the  bony  and  den- 
tinal tissues,  the  encroachment  of  the  affection  upon  the  den- 
tine was  so  slight  that  cross-sections  presented  merely  a  narrow 
streak  of  carious,  blackish-brown  discoloration.  No  finely 
granular  contents  were  visible  in  the  dentinal  canals  adjacent 
to  the  affected  portions,  and  no  leptothrix-mass  was  attached  to 
the  latter. 

The  strong  bony  tissue  of  the  premolar  became  undermined  by 
the  carious  process  in  such  a  manner,  that  carious  cavities  were 
met  with  at  a  considerable  depth  below  the  grinding  surface. 
Here,  also,  the  light-brown  discoloration  involved  only  a  few  rows 
of  bone-corpuscles  which,  together  with  the  interglobular  sub- 
stance, were  uniformly  pervaded. 

The  exterior  of  the  carious  bony  tissue  of  the  tooth  was  free 
from  leptothrix;  the  peripheral  layers  of  the  latter  tissue,  as 
well  as  of  the  carious  dentine,  had  a  more  homogeneous,  trans- 
parent appearance ;  it  is  still  undecided  if  it  be  allowable  to  re- 
gard this  as  a  slow  process  of  decalcification. 

Theories  op  Caries. — From  the  historical  account  whicli 
has  been  given,  it  is  evident  that  the  theory  of  caries  has  been 
sought  for  chiefly  in  three  directions  ;  some  have  given  promi- 
nence to  the  vital,  others  to  the  purely  chemical  and  to  the 
parasitic  processes,  and  still  others  have  advocated  divers  views, 
based  upon  various  combinations  of  the  latter  processes. 

Formerly,  the  knowledge  of  the  structure  of  the  tooth  was  so 
defective  that  there   was  no  anatomical  basis  for  the  study  of 


412  ANOMALIES    OF    THE    SECRETIONS. 

the  carious  process,  and,  until  the  fourth  decade  of  the  present 
century,  when  the  histology  of  the  tooth  became  determined  by 
degrees,  it  was  impossible  for  an  accurate  investigation  of  the 
structural  changes  in  the  carious  tooth  to  be  made.  In  order 
to  complete  our  knowledge  of  the  subject,  however,  a  gap  re- 
mained to  be  filled  up,  until  within  the  last  ten  years,  namely, 
the  establishment  of  the  history  of  the  development  upon  a 
sound  basis.  As  soon  as  these  preliminary  results  were  ob- 
tained, it  became  possible,  with  the  aid  of  the  improvements  in 
optical  instruments,  to  trace  the  process  in  its  different  phases. 

The  writers  of  the  earlier  times,  for  the  most  part,  were  vi- 
talists,  since  they  professed  to  recognize  a  life  in  the  tooth  and 
appear  to  have  referred  the  destructions  attending  dental  caries, 
resembling,  in  the  general  appearances,  the  gangrene  of  other 
organs,  to  a  vital  process. 

As  soon,  however,  as  organic  chemistry  furnished  the  analyses 
of  the  tooth  and  secretions  of  the  mouth,  although  these  are  still 
unsatisfactory,  and  explained  the  process  of  fermentation  with 
its  manifold  products,  it  became  necessary,  in  connection  with 
the  decalcification  process  in  dental  caries,  to  take  into  account 
the  action  of  acids  developed  in  the  secretions  or  in  fermenta- 
tion.    Hence  arose  the  chemical  theories. 

During  the  past  ten  years,  our  knowledge  with  reference  to  the 
marked  diffusion  of  parasites  and  their  injurious  efi'ects  upon  the 
animal  economy  has  gradually  increased ;  search  was  made  for 
such  animated  beings  in  the  carious  tooth ;  they  were  found,  or 
were  supposed  to  have  been  found,  and  hence  the  parasitic  theory 
was  constructed. 

Then  came  the  fusionists,  some  of  whom  attempted  to  com- 
bine the  vital  and  the  chemical  theories  of  dental  caries  and 
considered  the  latter  to  be  a  reaction,  of  the  nature  of  an  inflam- 
matory process,  on  the  part  of  the  hard  dental  tissue  which  is 
chiefly  affected,  the  dentine,  and,  at  the  same  time,  retained  the 
views  with  regard  to  the  agencies  in  the  process  of  decalcifica- 
tion. Another  class  combined  the  effects  of  chemical  agents 
with  those  of  parasites.  Still  another  class  endeavored  to  unite 
all  these  theories  and,  therefore,  assumed  the  occurrence  of 
several  kinds  of  caries.  •  It  was  admitted  that  the  caries  is  de- 


THEORIES    OF    CARIES.  413 

pendent,  in  most  cases,  upon  external  agencies  and  extends 
from  the  outside  towards  the  interior,  but,  on  the  other  hand, 
it  was  asserted  that  the  same  process  may  also  take  place  in 
the  opposite  direction  and  hence  caries  which  is  developed  from 
the  pulp  towards  the  exterior  was  described  as  caries  interna. 

Since  we  know  that  an  interchange  of  material  takes  place 
in  the  dentine  and  cement  during  life,  as  is  proved  by  the  occur- 
rence of  atrophies,  hypertrophies  and  new-formations.,  and  that 
the  dentine  possesses  a  degree  of  sensibility,  we  cannot  reject 
absolutely  the  idea  of  a  reaction  on  the  part  of  both  hard  tissues 
against  the  effects  of  external  agents.  Some  authors  seem  to 
have  had  an  intimation  of  this  idea,  since  they  were  inclined  to 
consider  the  textural  changes  in  carious  dentine  as  vital  pro- 
cesses. 

There  can  be  no  doubt  that  the  sensibility,  sometimes  increas- 
ing to  actual  pain,  of  the  dentine,  when  deprived  of  its  protec- 
tive covering,  is  a  vital  action,  and  that  this  becomes  diniinished 
when  the  most  sensitive,  the  peripheral  portion,  is  destroyed  by 
an  external  agent.  These  facts,  however,  are  by  no  means  suf- 
ficient to  enable  us  to  draw  a  conclusion  in  favor  of  the  reac- 
tionary power  of  dentine  in  parts  which  are  attached  by  caries. 

The  thickening  and  varicous  swellings  of  the  dentinal  fibrils 
were  ascribed  to  a  vital  process  by  J.  Tomes,  E.  Neumann  and 
H.  Hertz.  The  former  asserts  that  the  outlines  of  the  forma- 
tive cells  are  restored  by  the  diseased  condition  ;  E.  Neumann 
goes  still  farther  and  observes  a  proliferation  of  cellular  elements 
of  the  dentine  in  sections  which  have  been  colored  with  carmine, 
and  hence  establishes  an  analogy  between  dental  caries  and  in- 
flammatory and  ulcerative  processes  in  the  soft  parts.  Leber 
and  Rottenstein  merely  state  that,  in  cross-sections  especially, 
the  contents  of  the  Avidened  canals  are  seen  to  be  broken  up  into 
rod-like  segments  which,  sometimes,  are  separated  by  slight  in- 
tervals. They  did  not  find,  nor  have  I  succeeded  in  observing 
the  prominent  nucleiform  bodies  in  the  thickened  dentinal  fibrils, 
after  coloring  the  specimen  with  carmine,  as  they  were  described 
and  illustrated  by  Neumann. 

The  increased  transparency  of  the  dentine  around  the  focus 
of  caries  and  the  still  problematical  calcification  of  the  dentinal 


414  ANOMALIES    OF    THE    SECRETIONS. 

fibrils  are  regarded  by  J,  Tomes  as  attempts  on  the  part  of  na- 
ture to  arrest  the  progress  of  caries.  The  carious  dentinal  cone 
is  interpreted  by  Magitot  as  an  evidence  of  a  reaction  on  the 
part  of  the  pulp  against  the  agent  which  acts  from  the  outside. 
This  condition  of  irritation,  he  says,  is  manifested,  on  one  side,  by 
the  production  of  secondary  dentine  and,  on  the  other,  by  a 
molecular  deposit  in  the  dentinal  canals  Avhich  become  obliter- 
ated. He,  therefore,  regards  the  latter  appearance,  also,  as  a 
vital  process. 

Although  it  cannot  be  denied  that  the  living  pulp  does  react 
against  external  agencies,  still  the  interpretations  of  the  above- 
named  writers,  according  to  which  an  inflammatory  process  of 
the  pulp  manifests  itself  in  carious  dentine  in  the  different  ways 
already  mentioned,  are  incorrect,  as  Leber  and  Rottenstein  have 
shown.  Carious  dentine  of  reinserted  human  teeth  and  of  arti- 
ficial teeth  made  from  the  ivory  of  the  hippopotamus  presents 
the  sanie  appearances  as  are  found  in  ordinary  caries,  in  respect 
of  the  pigmented,  dark  and  light  zones,  the  granular  condition 
of  the  dentinal  fibrils,  the  thickening  and  varicous  enlargement 
of  the  latter.  The  phenomena  ascribed  to  odontitis,  therefore, 
do  not  really  belong  to  it. 

Dentinal  new-formations,  which  are  developed  upon  the  wall 
of  the  pulp-cavity  at  a  point  corresponding  to  the  carious  locality 
in  the  dentine,  can  be  induced  only  by  an  irritation  in  the  con- 
tiguous portion  of  the  pulp ;  they  are  an  expression  of  the  efforts 
of  nature,  a  reparative  tissue,  to  compensate  for  the  peripheral 
destruction.  They  are  particularly^  frequent  in  connection  with 
caries  with  a  tendency  to  a  chronic  character.  Numerous  cases 
present  no  trace  of  such  repair,  although  the  dentine  presents 
all  the  appearances  which  have  been  mentioned.  Inflammatory 
affections  of  the  pulp  generally  do  not  make  their  appearance 
until  the  dentine  has  suffered  a  considerable  loss  of  substance, 
or,  as  is  the  case  frequently,  until  the  pulp  is  covered  by  a  thin 
layer  of  dentine,  merely,  or  a  perforation  into  the  pulp-cavity 
has  occurred.  There  are  no  grounds,  then,  for  ascribing  the 
changes  in  the  dentinal  fibrils  to  an  inflammatory  irritation  of 
the  pulp. 

It   is   a  familiar   fact,   that  dead  animal   tissues   undergo  a 


THEORIES    OF    CARIES.  415 

marked  fatty  degeneration  under  certain  circumstances.  In 
pathological  cases,  a  fatty  metamorphosis  of  organs  is  frequently 
met  with,  and  this  fact  has  been  adduced,  in  some  cases,  to  prove 
that  fat  is  formed  by  the  transformation  of  protein  substances. 
It  is  not  singular,  therefore,  that  fat  may  also  be  deposited, 
under  favorable  circumstances,  in  dead  dentine ;  indeed  it  is 
found  interposed  in  the  dentinal  canals  in  the  form  of  drops. 

On  the  other  hand,  there  is  abundant  proof  that  fungi  pene- 
trate living,  dying,  and  dead  animal  tissues,  and  there  is  a 
fungus,  probably  belonging  to  Mucor,  Avhose  spores  sometimes 
are  found  in  drinking-Avater,  and  which,  by  proliferation  in  the 
dead  bone  and  dentine,  produces  a  considerable  loss  of  substance.  * 
This  fungus  has  no  connection  with  caries  of  the  tooth  and 
occurs  casually  in  carious  teeth  which  are  kept  in  water.  Quite 
as  little  is  the  part  taken  by  the  Protococcus  dentalis,  described 
by  Klenke  as  occurring  in  association  with  a  special  form  of 
caries,  which  he  termed  vegetative  decay  of  the  teeth  (Zahn- 
verderbniss).  I  have  met  with  tliis  in  a  single  instance;  its 
relation  to  dental  caries  has  not  been  confirmed  by  any  writer ; 
it  is  an  accidental  occurrence,  like  the  Puccinia  graminis  in  the 
favus  crust. 

Leptothrix  buccalis,  on  the  contrary,  occurs  so  frequently  in 
connection  with  dental  caries  and  so  clearly  lodges,  here  and 
there,  in  the  cartilage-like,  softened,  decalcifying  dentine,  that 
Leber  and  Rottenstein  went  so  far  as  to  state  that  the  variations 
in  the  course  of  caries  must  depend  upon  the  part  taken  by  the 
fungus  proliferation  in  the  carious  process.  The  proliferations 
of  the  elements  of  the  fungus  without  doubt  penetrate  and  ex- 
pand the  dentinal  canals,  but,  according  to  my  observations,  this 
cannot  occur  until  the  decalcification  of  the  dentine  is  complete, 
or,  at  all  events,  until  the  first  stage  of  this  process.  I  have 
never  detected  a  proliferation  of  fungus  in  the  deeper  layers  of 
the  still  hard,  carious  dentine,  and,  in  my  opinion,  the  death  of 
a  certain  amount  of  dentine,  in  consequence  of  the  action  of  the 
acid,  is  necessary  before  it  is  possible  for  the  proliferation  of 

*  C.  Wedl :  Ueber  einen  ira  Knochen  unci  Zahnbein  keimenden  Pilz. 

Sitzunffsber.  der  kais.  Akad.  d.  Wiss.  zii  Wien,  18fJ4. 


•il6  ANOMALIES    OF    THE    SECRETIONS. 

the  fungus  to  occur.  The  extension  of  caries,  in  the  dentine, 
therefore,  according  to  mj  view,  is  effected  by  the  acid  and  not 
by  the  fungus.  If  the  acid  be  neutralized  by  the  saliva,  e.  g., 
on  the  lower  incisors,  caries  does  not  occur,  notwithstanding 
the  presence  of  thick  layers  of  leptothrix,  such  as  are  met  with 
in  tartar.  Leptothrix  has  no  direct  connection  with  the  origin 
of  caries;  previous  to  the  formation  of  a  carious  pit  on  the  neck 
of  the  tooth,  I  have  been  unable  to  find  any  deposit  of  leptothrix 
upon  the  exterior,  or  any  rows  of  leptothrix-grains  in  the  in- 
terior, of  the  dentine.  The  grains  which  occur  in  the  dentinal 
canals  in  chronic  caries  are  minutely-divided  fat. 

The  action  of  an  acid,  therefore,  I  consider  a  fundamental 
condition  of  the  occurrence  of  caries  in  all  cases  where  there  is 
evidence  of  a  decalcification,  however  slight.  In  other  cases, 
where  no  evidence  of  the  latter  has  been  furnished  (in  a  manner, 
indeed,  not  to  be  relied  upon,  as  in  the  caries  carbonacea,  as  it 
is  termed  by  dentists),  the  chemical  process  is  still  in  darkness. 

Although  the  action  of  acids  is  admitted,  still  our  knowledge 
is  not  yet  sufiicient  to  enable  us  to  answer  the  questions,  whether 
one  or  several  acids,  what  form  of  the  same,  how  and  where  they 
are  formed  ? 

The  constituents  of  the  mixed  saliva  vary,  not  merely  in  dif- 
ferent persons  but,  also,  in  the  same  individual.  Its  well-known 
property  of  converting  insoluble  starch  into  dextrine  and  grape- 
sugar,  which  latter  may  enter  upon  an  acetous  fermentation  in 
the  presence  of  a  ferment,  was  turned  to  account  by  Leber  and 
Rottenstein,  who  concluded  that  the  acid  reaction  in  the  oral 
cavity  is  due  principally  to  the  acetous  fermentation  of  particles 
of  food.  If  it  is  proper  to  give  such  prominence  to  the  latter, 
then  it  will  be  impossible  to  understand  why  caries  of  the  teeth 
is  such  a  very  rare  occurrence  with  animals,  which  are  unable 
like  men  to  remove  the  particles  of  food  that  remain  between 
the  teeth.  Many  races  of  men,  who  certainly  are  not  very 
careful  in  observing  cleanliness  of  the  mouth,  e.  g.,  the  Esqui- 
maux and  New  Zealanders,  furnish  a  very  small  percentage. 
In  well-marked  chronic  caries,  the  remains  of  food  manifest  no 
perceptible  action ;  in  so-called  central  caries,  also,  a  cartilaginous 
softening  of  the  dentine  ensues  without  the  co-operation  of  the 


THEORIES    OF    CARIES.  417 

remains  of  food.  With  many  derangements  of  the  intestinal 
tract  an  acid  or  saline  taste  is  observed,  entirely  independent 
of  the  food.  Acid  sputa,  increased  acidity  of  the  vaginal  or 
vesical  mucous  membrane  attest  that  mucous  membranes  of 
themselves  may  furnish  an  abnormal  acid  secretion. 

Magitot  considers  the  saliva  to  be  the  active  agent  in  the 
production  of  caries,  when  the  former  becomes  the  vehicle  of 
acid  substances.  Leber  and  Rottenstein  state  that,  if  it  is  true 
that  fungi  play  any  part  in  the  acetous  fermentation  within  the 
oral  cavity,  a  point,  however,  which  remains  to  be  proved,  they 
are  inclined  to  ascribe  the  action  to  leptothrix,  and  assert  in 
common  with  Oehl,  that  in  all  probability  lactic  acid  is  formed 
in  the  acetous  fermentation.  Spence  Bate*  holds  the  view,  that 
in  consequence  of  a  decomposition  of  the  dentinal  fibrils  within 
the  tubes,  carbonic  acid  is  set  free  ;  the  latter  in  statu  nascenti, 
is  brought  into  contact  with  the  calcareous  salts  of  the  tissue, 
which  then  become  decomposed  with  the  development  of  acid. 
The  acid  which  is  set  free,  he  says,  is  phosphoric  and  not  lactic 
acid. 

In  my  opinion,  especial  consideration  is  claimed  by  the  secre- 
tion of  the  gums,  which  comes  into  immediate  contact  with,  and 
forms  a  partial  viscid  covering  of  the  teeth.  It  is  found,  often- 
times, to  be  acid  without  the  presence  of  the  debris  of  food. 
When  the  secretion  is  unusually  abundant,  as,  for  instance, 
with  children,  young  persons  and,  especially,  with  women  during 
pregnancy,  caries  assumes  a  more  or  less  acute  character.  It  is 
not  uncommon,  remarks  Tomes,  with  persons  who  have  many 
carious  teeth,  to  find  the  gums  swollen,  very  vascular,  and 
covered  Avith  a  coating  of  thick,  adhesive  mucus  which  may  be 
drawn  from  the  gums  in  long  strings.  He  mentions  a  case 
where  the  teeth  were  rapidly  destroyed  by  caries  and,  coincident 
with  this  process,  the  salivary  secretion  was  scanty  in  amount ; 
at  a  later  period,  the  whole  of  the  remaining  teeth  were  almost 
simultaneously  attacked  near  the  edge  of  the  gum,  producing 
around  each  tooth  an  annular  belt  of  softened  tissue.  He  states 
that  when  there  is  an  abundant  flow  of  saliva  and  a  free  secre- 

*  Odontological  Society  of  Gre:it  Britain  Keports,  1865. 
27 


418  ANOMALIES    OF    THE    SECRETIONS. 

tion  of  mucus,  the  latter  is  fouml  clinging  to  the  teeth,  instead 
of  becoming  dissolved  in  the  saliva,  and  that  the  mucus  must  be 
regarded  as  furnishing  the  agent  by  which  the  dental  tissues 
are  decomposed.  Tomes'  conclusion,  that  the  gum  when  irri- 
tated may  furnish  an  acid  secretion,  Avhich  he  regards  as  justified 
by  the  fact  that  caries  already  existing  is  promoted  by  the  in- 
sertion of  cotton  between  the  teeth,  is  invalid,  as  Leber  and 
Rottenstein  have  shown,  since  these  results  may  be  due  to  the 
fact  that  the  cotton,  being  a  porous  substance,  necessarily  favors 
the  processes  of  decomposition  and  fermentation  which  are  in 
progress  in  the  vicinity.  I  have  frequently  met  with  tumefaction 
of  the  gum  and  papillary  hypertrophy  in  association  with  dental 
caries  in  the  cadaver ;  these,  to  be  sure,  may,  in  part,  be  con- 
secutive affections,  still  the  frequent  coincident  occurrence  of 
an  affection  of  the  gum  is  deserving  of  notice. 

When  there  is  a  diminished  secretion  of  oral  fluids  and  from 
the  gum,  as  is  the  case  in  old  age,  caries  assumes  a  well-marked 
chronic  course.  In  those  localities,  where  only  a  slight  action 
of  the  secretion  of  the  gum  is  possible  or  the  latter  is  removed 
readily  by  the  movements  of  the  tongue,  caries  is  a  rare  occur- 
rence. When  the  caries  is  acute  and  the  crown  is  destroyed, 
its  progress  in  the  roots  is  a  slow  process,  in  consequence  of  the 
fact  that  the  action  of  the  secretion  of  the  gum  becomes  less 
direct.  While  the  greatest  prominence  is  given  to  the  action  of 
the  abnormal  secretion  of  the  gums,  it  must  not  be  assumed  that 
the  influence  of  the  anomalies  in  the  secretions  of  the  salivary 
and  mucous  glands  and  of  the  mucous  membrane  of  the  oral 
cavity  is  underrated,  as,  indeed,  is  sufficiently  apparent  from 
the  preceding  observations.  Injurious  effects,  however,  as  a 
general  rule,  are  to  be  ascribed  to  the  debris  of  food  only  in 
cases  where  the  structure  of  the  tooth  is  defective  or  there  is  a 
carious  breach  of  substance. 

It  must  be  acknowledged  that  our  knowledge  with  regard  to 
the  quality  of  the  secretions  of  the  oral  cavity  is  imperfect  and, 
at  all  events,  it  is  a  question  whether  the  injurious  effects  are 
due  to  them  alone  or  rather  to  the  products  of  their  decomposi- 
tion. It  is  not  known  whether  a  larger  or  smaller  amount  of  an 
acid  (perhaps  lactic,  and  with  regard  to  which  organic  chemistry 


THEORIES    OF    CARIES.  419 

teaches  us  that  it  occurs  frequently  in  partially-decomposed 
animal  fluids)  shortens  or  prolongs  the  process,  or  if  different 
acids  modify,  in  various  ways,  the  course  of  caries.  The 
presence  of  lactic  acid,  particularly,  is  assumed  since  C.  Schmidt, 
of  Dorpat,  has  succeeded  in  demonstrating  the  frequent  occui'- 
rence  of  this  acid  in  the  usually  acid  juice  (Saft)  obtained  from 
long  bones  affected  with  osteomalacia.  It  also  remains  to  be 
decided  whether  butyric,  valeric,  or  formic  acids,  which  H. 
Fischer  obtained  from  strongly-alkaline  or  acid  pus,  do  not 
occur  as  products  of  the  decomposition  of  the  puriforra  secretion 
of  the  gums. 

If  the  continuity  of  the  enamel  membrane  is  interrupted  by 
fissures  in  the  enamel,  or  has  become  brittle  and  friable  in  conse- 
quence of  the  presence  of  leptothrix  masses,  and  acids  have  access 
to  the  enamel,  then  the  calcareous  salts  within  the  prisms  are 
reached  quite  readily  since  the  organic  investments  of  the  latter 
are  capable  of  offering  only  slight  resistance ;  indeed,  we  learn 
by  chemical  analysis  that  the  organic  substances  of  the  enamel 
amount  to  scarcely  more  than  three  per  cent.  Primarily,  the 
action  of  the  acid  is  confined  to  narrow  limits,  and  it  may  be 
assumed  upon  good  grounds  that  a  simple  solution  of  the  cal- 
careous salts  does  not  take  place,  but  that  the  acid  enters  into 
combination  with  the  latter  and  the  newlj'^-formed  salts,  destitute 
of  an  organic  cement,  readily  become  disintegrated.  If  we  con- 
sider that  the  acid  spreads  in  the  course  of  the  groups  of  enamel 
fibres,  it  will  readily  be  understood  that,  on  the  one  side,  the 
action  is  confined  to  definite  limits  and,  on  the  other,  an  under- 
mining of  the  adjacent  portions  of  the  enamel  ensues.  If  the 
continuity  of  the  enamel  prisms  is  broken,  the  normal  transpar- 
ency of  the  enamel,  at  the  corresponding  part,  is  destroyed  and 
a  white  spot  makes  its  appearance.  If  the  action  of  the  acid  is 
slow,  we  find  a  more  abundant  deposit  of  pigment.  Possibly, 
decalcification  and  putrefaction  occur  in  common  in  this  case. 

When  a  circumscribed  breach  of  substance  has  been  efi'ected 
in  the  enamel,  materials  entering  from  the  outside,  tenacious 
mucus,  leptothrix  and  particles  of  food,  are  more  likely  to  be- 
come impacted  in  the  jagged  excavation  which  then  affords  a 
more  favorable  locality  for  the  action  of  acid  ;  with  this  condi- 


420  ANOMALIES    OF    THE    SECRETIONS. 

tion,  the  acid  continues  its  deleterious  action  undisturbed  by  tlie 
neutralizing  property  of  the  salivary  fluid,  and  its  effects  are 
manifested  by  a  yellowish  discoloration  of  the  adjacent  portions 
of  the  dentine,  even  while  the  latter  is  still  covered  by  a  thin 
layer  of  enamel.  • 

As  will  be  evident,  the  larger  the  carious  cavity  in  the  enamel 
and  the  smaller  the  aperture  leading  to  it,  so  much  the  greater 
will  be  the  danger  that  the  dentine  will  be  extensively  involved. 
As  the  dentine  contains  28  per  cent,  of  organic  matter,  the  pro- 
cess of  decalcification  in  it  takes  place  quite  rapidly  leaving  be- 
hind the  organic  residue,  the  so-called  dental  cartilage.  In  con- 
sequence of  the  action  of  the  acid,  death  of  the  affected  dentine 
ensues,  and  its  decomposition,  in  which,  as  above  observed,  lep- 
tothrix  buccalis  is  the  active  agent,  takes  place  from  the  exterior 
towards  the  central  portions.  A  carious  cavity  is  formed  in  the 
dentine,  usually  larger  than  that  in  the  enamel ;  this  affords  a 
receptacle  for  particles  of  food,  which  frequently  cannot  be 
reached  except  with  difficulty,  and  hence  readily  becomes  the 
seat  of  acetous  fermentation. 

The  shape  of  the  carious  cavities  in  the  enamel  and  dentine 
depends  partly  upon  the  location  in  the  tooth  and  partly  upon 
the  quality  of  the  enamel  and  dentine.  Near  the  neck  of  the 
tooth,  the  carious  excavations  are  flattened,  while  those  upon 
the  masticating  surfaces  of  the  molars  are  always  very  large  in 
comparison  with  the  orifices  leading  to  them.  The  thicker  and 
more  compact  the  enamel,  the  greater  resistance  does  it  offer 
and  the  more  extensive  is  the  destruction  of  the  dentine  beneath 
the  enamel ;  in  these  cases,  therefore,  the  cavity  is  always  very 
deep,  while  flattened  cavities  occur  where  the  enamel  is  thin  and 
has  a  more  lax  structure.  The  greater  the  extent  of  the  ex- 
posed dentinal  surface,  the  more  extensive  will  be  the  portions 
affected. 

The  cause  of  the  very  marked  carious  pigment  deposits  in  the 
enamel  and  dentine  remains  undetermined ;  it  cannot  lie  in  the 
organic,  changed  matter  alone,  since  the  discoloration  is  mani- 
fested with  equal  intensity  in  both  tissues,  and  between  the  latter 
there  is  a  marked  difference  in  respect  of  the  percentage  of  or- 
ganic matter  which  they  contain.      When  the  action  of  the  acid 


THEORIES    OF    CARIES.  421 

upon  the  enamel  and  dentine  takes  place  slowly,  the  intense, 
carious  pigmental  degeneration  does  not  extend  to  a  great  depth, 
the  cartilaginous  softening  is  limited  to  a  narrow  zone,  and  the 
disintegration  ensues  so  gradually  that  the  proliferating  lepto- 
thrix  buccalis  could  not  possibly  penetrate  except  to  a  very 
short  distance. 

The  distinction  between  caries  of  bone  and  of  dentine  is  il- 
lustrated by  caries  of  the  cement  which  is  characterized,  also,  by 
its  progress  from  the  exterior  towards  the  central  portion  of  the 
tooth  and  by  a  progressive  deposit  of  pigment,  together  with  a 
peripheral  softening.  In  the  premolar  of  the  horse,  where  the 
vascularized  osseous  substance  forms  such  thick  layers,  the  pro- 
cess is  the  same  as  in  the  cement  of  human  teeth,  with  the  ex- 
ception that  in  the  former  it  assumes  a  well-marked  chronic 
character.  The  death  of  the  osseous  substance  spreads,  gradu- 
ally, from  the  exterior  without  any  manifestation  of  an  inflam- 
matory reaction. 

Since,  then,  caries  gives  evidence  of  its  dependence  upon  ex- 
ternal causes  in  all  three  dental  tissues,  the  question  arises, 
what  processes  occur  in  connection  with  the  very  rare  softening 
and  melting  down  of  the  dentine  in  the  direction  from  the  pulp- 
cavity  towards  the  periphery  ?  A  case  has  been  related  (com- 
pare p.  191)  where  a  central  softening  of  the  dentine  occurred 
without  any  trace  of  ordinary  caries.  Leber  and  Rottenstein,* 
also,  report  a  case  of  so-called  central  caries,  where  a  bluish  dis- 
coloration appeared  upon  three  incisors  without  any  trace  of 
caries.  By  means  of  holes  made  in  two  of  them,  the  entire  in- 
ternal portions,  as  far  as  the  enamel,  were  found  to  be  com- 
pletely softened,  decomposed  and  of  a  brownish  hue ;  even  the 
roots  Avere  deeply  excavated.  The  third  tooth  was  not  touched. 
The  patient  recollected  that  she  had  a  fall,  in  her  childhood, 
striking  upon  the  teeth,  and  that  this  was  followed  by  a  swell- 
ing of  the  face.  Leber  and  Rottenstein  express  no  opinion  as 
to  the  cause  of  the  destruction  of  the  dentine  in  this  case  and 
state  that  such  cases  ought  not  to  be  confounded  with  ordinary 
dental  caries.  -  A.  Scheller,  of  Warsaw,t  reported  two  cases  of 

*  Op.  cit.,  p.  11.  t  Deutsche  Viertelj.  f.  Zahnh.,  1870. 


422  ANOxMALIES    OF    THE    SECRETIONS. 

this  description,  the  second  one  of  which  is  of  especial  interest 
and  is  simiLar  to  that  of  Leber  and  Rottenstein.  He  expresses 
an  opinion  that  the  central  caries  of  the  teeth  is  to  be  regarded 
as  a  process  of  decomposition  which  is  engendered  by  the  disor- 
ganization (Verjauchung)  of  the  pulp. 

The  condition  found  in  gangrene  of  the  pulp  (compare  p.  183) 
points  to  the  presence  of  a  fatty-acid  as  a  product  of  decompo- 
sition ;  it  may  be  possible,  then,  that  a  fatty-acid  is  formed  in 
the  necrotic  pulp,  capable  of  destroying  the  dentine.  Magitot 
ascertained  (compare  p.  408  et  seq.)  that  butyric  and  lactic 
acids  are  very  similar,  in  respect  of  the  mode  and  degree  of 
their  action  upon  the  teeth.  At  all  events,  the  so-called  central 
caries  cannot  be  regarded  as  a  variety  of  ordinary  caries,  but, 
obviously,  must  be  classed  with  the  inflammatory  affections  of 
the  pulp. 

"  In  proof  of  the  occurrence  of  an  internal  caries,  which  has 
been  classed  with  caries  of  bone,"  says  Ileider,  "  the  foul,  some- 
times exceedingly  nauseating  odor  occasioned  by  carious  teeth 
has  been  taken  into  account  and  referred  to  a  secretion  from 
carious  dentine.  But,"  he  continues,  "the  peculiar,  purulent 
odor  never  occurs  except  with  a  patent  pulp-cavity  and  arises 
from  the  gangrenous  pulp ;  while  the  foul  odor  of  carious  teeth, 
when  the  pulp-cavity  is  closed,  is  occasioned  by  the  putrefying 
debris  of  food,  which  accumulates  in  such  cavities,  and  disap- 
pears if  the  latter  are  kept  clean.  The  preceding  must  not  be 
confounded  with  the  foul  odor  occasioned  by  the  accumulation 
of  the  secretion  of  the  gum  between  the  teeth  and,  perhaps,  by 
coagulated  blood,  or  is  communicated  by  plugs  of  cotton  in  the 
cavities." 

The  carious  process  may  be  checked,  but  it  cannot  be  cured. 
An  acute  form  may  become  chronic,  and  an  arrest  may  ensue ; 
this  is  a  particularly  common  occurrence,  as  has  been  observed 
before,  on  the  carious  roots,  upon  which,  however,  it  is  possible, 
always,  to  discover  a  carious  superficial  layer  containing  deposits 
of  pigment. 

Duval*  and  various  other  authors  have  applied  the  term  caries, 

*  Magitot,  op  cit.,  p.  30. 


THEORIES    OF    CARIES.  423 

■which  resembles  a  ^^usure^''  (Usur),  to  a  partial  defect  which 
occurs  upon  the  neck  of  the  tooth,  and  has  been  described  as 
wedge-shaped  (comp.  p.  253).  Although  Magitot  admits  that 
these  defects  present  all  the  appearances  of  a  true  usure,  still  he 
•has  pronounced  them  to  be  instances  of  healed  caries  of  the 
neck  of  the  tooth  or  dry  caries,  without,  however,  adducing  any 
reasons  in  support  of  this  opinion.  The  healing  process  is  said 
to  be  induced  partly  by  the  resistance  of  the  pulp  and  partly 
by  the  removal  of  the  injurious  exciting  cause. 

The  action  of  the  acid  requires  a  certain  length  of  time, 
whether  the  secretions  of  the  gums,  the  lips,  the  buccal  raucous 
membrane  or  the  debris  of  food,  act  as  its  vehicle,  and  this 
period  is  shorter  or  longer,  as  the  local  relations  are  more  or 
less  favorable  for  the  reception  of  the  acid  vehicle.  Hence 
caries  makes  its  first  appearance  in  the  pits  and  grooves  or  on 
the  contiguous  and  facial  surfaces  of  the  teeth. 

The  effects  of  equivalent  acid  vehicles  vary  in  the  different 
kinds  of  teeth  in  the  same  individual  and,  also,  in  those  of  dif- 
ferent persons.  The  frequency  of  caries  is  diminished  under 
the  following  circumstances:  a,  if  the  effect  of  the  acid  is  neu- 
tralized, as  is  the  case  upon  the  lower  incisors  which  are  bathed 
in  saliva  almost  constantly,  and  upon  which  deposits  of  tartar 
are  very  common.  The  deposition  of  the  latter,  probably,  pre- 
vents the  occurrence  of  the  carious  process  in  the  contiguous 
locality,  but  still  chronic  caries  may  be  in  progress  upon  one 
surface,  while  the  deposit  of  tartar  takes  place  upon  another ; 
b,  if  the  position  of  the  teeth  is  corrected  so  that  their  contigu- 
ous surfaces  correspond  with  the  normal  arrangement;  c,  if  the 
teeth  receive  proper  care  and  they  are  protected  against  the 
action  of  injurious  agents;  d,  if  the  tooth  is  constructed  in  a 
solid  manner  and  its  surface  presents  a  normal  smoothness;  e, 
if  all  the  teeth  and  the  oral  mucous  membrane,  together  with 
the  glands,  are  regularly  constructed  with  reference  to  the  modi- 
fications engendered  by  race  and  hereditary  tendencies. 

The  last-mentioned  factor  is  the  most  important  element  in 
the  determination  of  the  frequency  of  caries  in  general  and  is 
intimately  connected  with  the  structure  of  the  entire  organism. 


424  ANOMALIES    OF    THE    SECRETIONS. 

The  quality  of  the  nutritive  material  has  only  a  secondary  im- 
portance. 

The  structure  of  the  individual  tooth  has  an  essential  influ- 
ence upon  the  course  of  caries,  and  the  teeth  may  be  divided 
into  groups  with  reference  to  their  power  of  resisting  the  dis- 
ease. Our  present  methods  of  investigation  are  not  yet  perfect 
enough  to  enable  us  to  determine  with  exactness,  the  individual 
differences  in  the  degrees  of  hardness  of  the  enamel  and  dentine, 
the  knowledge  of  which  is  of  importance  in  determining  the 
treatment  and  prognosis.  A.  Alphons,  of  CracoAV,*  divided  the 
teeth  into  six  classes,  with  reference  to  the  treatment  of  caries 
by  filing  and  filling. 

Heider  communicated  to  me  his  vicAvs  upon  this  point  as  fol- 
lows: With  regard  to  the  predisposing  conditions  in  the  struc- 
ture of  teeth  which  are  attacked  by  caries,  it  is  found  that  bluish 
or  grayish-white  teeth,  with  a  slight  polish,  very  frequently  are 
attacked  simultaneously  by  acute  caries,  while,  on  the  other  hand, 
yellowish-white  teeth,  with  smooth,  polished  enamel,  usually  are 
affected  by  chronic  caries  only,  and  in  isolated  cases.  The  first- 
named  kind  of  teeth  is  furnished  with  less  solid  enamel  and  less 
compact  dentine,  as  is  indicated  most  decidedly  by  the  use  of 
the  file  and  excavator.  Some  teeth  can  be  operated  upon  with 
great  ease,  even  with  inferior  files,  and  leave  upon  the  file  a 
large  quantity  of  dentine,  reduced  to  a  white,  unctuous  mass, 
while,  on  the  other  hand,  the  second  named  kind  of  teeth  off"ers 
great  resistance  to  the  action  of  the  file  and  is  affected  only  to 
a  slight  degree,  comparatively  speaking,  even  by  the  best  files, 
upon  which  they  leave  only  a  scanty,  white,  powdered  mass  of 
dentine.  The  enamel  and  dentine,  therefore,  present  two  varie- 
ties in  quality,  the  gradations  of  which  determine  the  varying 
susceptibility  of  the  teeth  to  caries. 

If  it  is  true,  as  Gladstone  cites  from  Lasseigne,  in  his  lectures,t 
that  the  molar  teeth  contain  a  greater  amount  of  mineral  sub- 
stance than  the  incisors,  and  that,  with  increasing  age,  the  teeth 
present,  especially,  a  large  decrease  in  the  amount  of  carbonate, 

*  Deutsche  Viertelj.  f.  Zahnheilk.,  1867. 

t  Qiuirterly  Journal  of  Dental  Science,  1857. 


THEORIES    OF    CARIES.  425 

as  compared  with  that  of  phosphate  of  lime,  then  we  should  have 
several  datas  as  to  the  course  of  the  carious  process  according 
to  the  kind  of  tooth  affected  and  to  the  aoje. 

From  the  foregoing  observations,  it  appears  that  caries  of  the 
teeth  is  a  process  which  has  its  origin,  chiefly,  in  the  abnormal  se- 
cretions of  the  gums  and,  likewise,  in  those  of  the  rest  of  the  oral 
mucous  membrane  and  of  the  salivary  glands,  and,  commencing 
at  suitable  points  upon  the  exterior  of  the  tooth,  spreads  in  the 
direction  of  the  pulp-cavity.  In  consequence  of  the  decomposi- 
tion of  the  secretions,  acids  are  formed  which  extract  the  cal- 
careous salts  from  the  hard  tissues  and  give  rise  to  a  disinte- 
gration of  the  afl'ected  portions  of  the  latter,  in  which  no  inflam- 
matory reaction  occurs.  The  destructive  process  is  promoted, 
essentially,  by  the  accumulations  of  secretions  and  particles  of 
food,  and  opportunity  is  aff"orded  for  the  proliferation  of  lepto- 
thrix  buccalis,  in  the  dead  and  softened  dentine.  The  exclusion 
of  an  acid  in  the  development  of  well-marked  chronic  caries 
(caries  sicca,  carbonacea  of  writers)  is  not  established  upon 
scientific  grounds. 


426  NEUROSES. 


YII.  NEUROSES. 

Under  this  head  we  have  to  consider  the  disorders  of  sensi- 
bility Avithin  the  territory  of  the  trifacial  nerve  which,  as  we 
know,  is  a  mixed  nerve,  being  composed,  for  the  most  part,  of  sen- 
sitive, but,  also,  containing  motor  and  secretory  fibres.  The  por- 
tion of  its  territory  of  particular  interest  to  us  includes  the 
branches  of  the  second  and  third  divisions,  which  supply  the 
teeth  and  gums  on  the  corresponding  side,  but,  at  the  same  time, 
it  is  necessary  to  keep  in  view  the  territory  of  the  other  ramifi- 
cations, the  points  of  their  origin,  together  with  the  numerous 
anastomoses  and  ganglionic  communications  throughout  the  en- 
tire course  of  the  nerves,  in  order  to  appreciate  fully  the  com- 
plicated morbid  phenomena  of  nerve-life. 

In  consequence  of  the  obscure  nature  of  the  subject  and  our 
present  imperfect  means  of  observation,  only  a  few  anatomical 
changes  in  the  nerves  and  ganglions  in  neuralgias  are  recognized. 
I  had  the  opportunity  of  examining  a  series  of  nerves  which  were 
resected  by  Schuh  for  the  relief  of  facial  neuralgia,  and  satisfied 
myself  that,  in  the  majority  of  cases,  it  is  possible  to  demonstrate 
disordered  conditions  both  in  tlie  neurilemma  and  in  the  nerve- 
tubes.  In  the  former,  an  hypersemic  swelling  occurs,  and  the  in- 
terstitial connective  tissue  of  the  nerve-tubes  acquires  a  finely 
granular  cloudiness  ;  in  the  latter,  a  finely  granular  metamor- 
phosis of  the  medulla  is  observed.  The  latter  abnormal,  refrac- 
tive, protruding  contents,  however,  are  found  only  in  separate 
tubes  or  in  a  small  group  of  tubes,  while  the  remaining  tubes 
contain  a  perfectly  normal  medulla.  In  old  chronic  cases,  pig- 
mented granular  spots  are  found  in  the  neurilemma,  and  a  crum- 
bling disintegration  of  the  greater  portion  of  the  medulla  is  ob- 
served. The  grains  which  fill  and  protrude  from  the  nerve- 
tube,  sometimes,  are  quite  large,  glittering,  and  roundish,  at 
others,  minute  molecules;  the  axis-cylinders,  when  removed, 
present  similar  grains   which  are   adherent  and  collected  to. 


EXCITING    CAUSES    OP    NEURALGIAS.  427 

gether  in  clusters.  In  one  instance,  I  found  quite  large,  highly 
refractive,  roundish  bodies,  symmetrically  arranged  in  longitu- 
dinal chains  and  resting  upon  separate  nerve-tubes.  These  were 
entirely  soluble  in  hydrochloric  acid  and,  therefore,  were  calca- 
reous grains.  They  were  also  found  interspersed  in  the  inter- 
stitial connective  tissue. 

These  appearances  which  have  been  described  clearly  indi- 
cate that,  in  most  cases,  a  netoritic  process  [neuritis]  ensues,  which 
pursues  a  more  or  less  active  course  and,  in  protracted  cases* 
induces  an  obliteration  of  the  nerve-medulla. 

Rosenthal*  also  mentions  knotty  swellings  of  resected 
branches  of  the  trifacial  nerve  (consisting  of  connective  tissue 
and  interposed  nerve-fibres),  like  the  knots  which  are  met  with 
in  the  divided  nerves  after  amputations. 

We  know  nothing  in  regard  to  the  affections  of  the  ganglions 
in  the  course  of  the  trigeminus,  in  connection  with  neuralgias; 
in  one  instance,  in  a  case  of  prosopalgia,  I  found  an  evident 
pathological  change  in  the  Gasserian  ganglion. f  The  ganglions 
on  both  sides  presented  numerous  calcareous  grains  of  various 
forms.  The  ganglionic  cells  contained  abundant  deposits  of 
pigment.  The  ganglion  of  the  affected  side  presented  a  quite 
noticeable  swelling,  and  the  bloodvessels  of  the  connective  tissue, 
which  invested  it  and  surrounded  the  nerve-bundles  of  the  nodu- 
lar enlargement,  were  very  full  of  blood,  so  that  there  could  be 
no  doubt  of  a  previous  exudative  process  in  this  ganglion.  An 
inflammatory  affection  at  the  point  of  origin  of  the  trifacial 
nerve  was  observed  by  Bensow,  and  Beveridge  described  a  new- 
formation  upon  the  trunk  of  the  fifth  nerve. 

These  inflammatory  processes  in  the  continuity  of  the  trifacial 
nerve  are  consecutive  in  most  cases,  and  may  have  their  focus 
of  irritation  (Reizungsherde)  at  the  periphery  of  the  branches 
of  the  second  and  third  divisions,  the  consideration  of  which  is 
involved  in  our  present  subject.  The  following  are  the  exciting 
causes  of  neuralgias  within  the  precincts  under  consideration ;  a, 
chronic  inflammation  of  the  pulp,  since  this   and  its  products 


*  Handbuch  der  Kinderkrankheiten,  p.  490. 
f  Schuh  Ueber  Gesichtsneuralgien,  p.  19. 


428  NEUROSES. 

maintain  a  constant  irritation  of  the  pulp-nerves;  b,  new-forma- 
tions of  hard  dental  tissues  within  the  pulp,  inasmuch  as  they 
irritate  the  remaining  nerves  of  the  pulp,  under  certain  circum- 
stances; (?,  proliferations  of  cement  at  the  extremities  of  the 
roots,  whereby  the  nerves  which  enter  the  teeth  are  bent  more 
or  less  from  their  proper  course  or  the  same  nerves  at  a  dis- 
tance from  the  apices  of  the  roots,  together  with  the  nerves  of 
periosteum  of  the  root,  are  irritated;  d,  chronic  inflammation  of 
the  root-membrane,  with  its  sequelae,  particularly  in  the  vicinity 
of  the  apex  of  the  root;  e,  new-formations  of  the  root-mem- 
brane when  they  encroach  upon  the  precincts  of  the  nerve- 
branches;  /,  periostitis,  especially  in  the  grooves  or  the  foramina 
which  serve  for  the  transit  of  the  dental  nerves  ;  g,  osteophytes, 
which  occasion  an  irritation  of  the  periosteal  nerves ;  h,  tume- 
faction of  the  mucous  membrane  and  periosteum  of  the  antrum 
of  Highmore  give  rise  to  pain  and  even  a  neuralgia  of  the  pos- 
terior, superior  dental  nerves  (Schuh)  in  otherwise  sound  teeth, 
which  circumstance  Luschka  explains  by  the  fact  that  the  dental 
nerves  pass  through  complete  bony  canals  in  some  places,  but  in 
others  lie  in  very  shallow  grooves  in  the  bone,  so  that  they  are  in 
immediate  contact  with  the  tissue  of  the  periosteum,  and,  if  the 
latter  be  removed,  they  become  exposed;  i,  anomalies  of  position, 
whereby  resorption  of  one  or  another  root  or  of  the  crown  of  the 
adjacent  tooth,  is  occasioned  by  the  growth  of  the  roots  of  the 
displaced  tooth,  and  the  contiguous  portion  of  the  root  of  the 
former  is  subjected  to  a  continual  irritation  ;  k,  teeth  which  re- 
main imbedded  within  the  jaw  sometimes  irritate  the  dental 
nerves  of  other  teeth  by  the  growth  of  their  roots ;  I,  inflamma- 
tory irritation  of  the  gingival  nerves  which  cover  the  coronal  por- 
tions of  teeth  during  the  first  dentition  ;  m,  inflammatory  irrita- 
tion of  the  gingival  nerves  in  connection  with  the  difficult  erup- 
tion of  teeth  during  the  second  dentition,  especially  of  the  wis- 
dom teeth ;  n,  tumors  of  the  jaws,  inasmuch  as  they  sometimes 
occasion  an  irritation  of  the  dental  nerves ;  o,  foreign  bodies 
which  have  penetrated  into  the  pulp ;  p,  lesions  produced  by 
unsuccessful  extractions  of  teeth. 

When  such  peripheral  foci  of  irritation  exist,  as  the  resected 
nerves  in  facial  neuralgia  show,  the   trunks,  from  which    the 


IRRADIATION    OF    THE    PAINS    IN    NEURALGIAS.  429 

dental  nerves  are  given  off,  become  inflamed,  their  sheaths  are 
found  in  an  hypersemic  condition,  and  hence  the  possibility  is 
afforded  for  communicating  nerves,  which  are  contained  in  a 
common  fibrous  envelope,  to  become  involved.  Moreover,  it  is 
readily  explicable  that  hyperesthesia  is  induced  by  inflammator}'' 
swellings  in  localities  where  the  radiation  of  the  divisions  of  the 
trifacial  nerve  is  confined  to  a  contracted  space.  Hyrtl*  calls 
attention  to  the  fact,  that  the  branches  of  this  sensitive  cranial 
nerve  traverse  tightly-inclosed,  long  canals  in  the  bones,  as  the 
infraorbital,  alveolar,  zygomatic  branches,  &c.,  and,  therefore, 
on  the  occurrence  of  nutritive  disturbances  of  their  sheaths 
from  rheumatism  or  congestion,  with  thickening  and  tumefac- 
tion, they  are  subjected,  necessarily,  to  pressure  which  is  mani- 
fested by  sensations  of  pain. 

Rosenthalf  states  that  periostitis,  involving  portions  of  the 
bones  through  which  the  passage  of  the  trifacial  nerve  takes 
place,  is  a  frequent  exciting  cause,  and  says  neuralgia  of  this 
nerve  is  due,  most  frequently,  to  exposure  to  cold.  Without 
detracting  from  the  influence  of  the  latter,  I  am  convinced, 
nevertheless,  that  in  most  cases  there  is  a  primary  neuritic  con- 
dition [neuritis]  of  a  peripheral  branch  of  the  trifacial  nerve, 
and  that  the  exposure  to  cold  simply  furnishes  a  cause  for  the 
farther  extension  of  the  previous  inflammatory  condition  in  the 
course  of  the  branches  of  the  nerve. 

Peripheral  irritations  of  the  trifacial  nerve,  as  we  knoAV,  fre- 
quently arise  at  the  point  of  exit  of  the  nerve  from  tlie  cranial 
cavity,  in  consequence  of  inflammatory  affections  or  tumors  at 
the  base  of  the  brain,  and  a  thorough  examination  is  required 
in  order  to  determine  whether  the  focus  of  ii-ritation  is  centric 
or  peripheric.  In  this  case,  it  is  supposed,  of  course,  that  the 
patient  refers  the  pain  to  the  periphery  and  not  to  the  irritated 
portion  of  the  nerve. 

Another  and  frequent  source  of  error,  in  the  determination  of 
the  focus  of  irritation,  arises  from  the  irradiation  of  the  pains, 
by  which  is  meant  that  they  extend  far  beyond  the  limits  of  the 

*  Topograph.  Anatomie,  5  Aufl.,  I,  p.  3-15. 
t  Op.  cit.,  p.  193. 


430  NEUROSES. 

seat  of  irritation  and,  sometimes,  are  more  severe  than  the  pain 
felt  at  the  original  focus  of  irritation.  In  these  facts,  we  have 
an  explanation  of  the  inexact  and  varying  statements  of  patients 
with  regard  to  the  locality  of  the  pain,  whereby  the  surgeon  is 
not  a  little  perplexed  in  deciding  upon  the  resection  of  one  or 
another  nerve. 

Further  proof  of  the  difficulty  attending  the  localization  of 
the  focus  of  irritation  is  furnished  by  the  fact  that  resection  of 
painful  branches  of  the  trifacial  nerve,  in  most  cases,  affords  only 
temporary  relief  from  pain,  which  rarely  continues  longer  than 
a  year.  Resection  of  a  sensitive  nerve  really  effects  nothing 
but  an  interruption  of  its  conductivity  and,  as  soon  as  the  latter 
is  restored  by  the  regeneration  of  the  nerve,  the  pain  is  renewed 
and  becomes  as  violent  as  it  was  previous  to  the  operation  ; 
hence  it  is  proved  that  the  focus  of  irritation  was  not  detected 
and  that  it  must  have  been  located  somewhere  else  than  in  the 
resected  portion;  the  irritation  persisted  after  the  resection,  but 
consciousness  of  it  was  lost  since  its  connection  with  the  brain 
Avas  cut  off. 

Another  important  question  arises:  Is  there  any  point  to 
which  the  pain  is  referred  constantly  ?  Schuh,*  after  very  ex- 
tensive observations,  came  to  the  conclusion  that  the  fixed  pain 
is  wanting  very  frequently,  although  Yalleix  maintains  the  op- 
posite view.  It  is  described  by  the  patients,  he  says,  as  dull, 
heavy,  gnawing,  dragging  and  somewhat  burning,  and  is  not 
perceived  throughout  the  entire  course  of  the  nerve  or  branch, 
but  is  limited  to  a  circumscribed  locality.  Usually,  it  is  not  very 
severe  and,  sometimes,  it  continues,  with  varying  intensity,  for 
hours  or  days  together.  I  am  disposed  to  agree  with  Schuh, 
since  it  is  a  physiological  fact  that  the  sensibility  of  nerve-fibres 
may  become  blunted,  at  least  for  some  time,  if  they  are  sub- 
jected to  severe  or  continued  irritation.  If,  however,  we  find 
no  continually  painful  locality,  it  becomes  a  more  difficult  matter 
to  ascertain  the  locality  of  the  focus  of  irritation. 

If  the  clinical  phenomena  indicate  such  a  fixed  point,  they 
may  be  divided  into  those  which  are  confined  to  the  focus  of 

*  Ueber  Gesichtsneuralgien,  1858,  p.  3. 


REFLEX    PHENOMENA.  431 

irritation,  local  or  'primary^  and  into  periodical  or  secondary. 
The  most  prominent  symptom  is  the  disorder  of  sensibility, 
which  we  term  pain.  Besides  the  sensitive  fibres  of  the  trifacial 
nerve,  its  motor  and  secretory  fibres  and  even  those  of  other 
nerves  are  attacked  by  reflex  action  through  the  small  reflex 
centres,  the  ganglions,  or  through  the  central  nervous  system. 
Fibres  of  the  sympathetic,  also,  become  involved  in  the  irritation. 

With  regard  to  the  localities  from  which  the  pain  radiates  in 
the  paroxysms,  Schuh  observes,  they  originate  either  at  the 
points  where  the  sensitive  branches  of  the  fifth  pair  emerge  from 
the  canals  or  grooves  of  the  bone  and  enter  the  soft  parts  of  the 
face,  in  the  peripheral,  terminal  ramifications  in  the  skin,  mucous 
membrane,  or  teeth,  or,  finally,  where  the  terminations  of  the 
two  divisions  of  the  nerve  join  or  communicate  with  one  another. 
Among  the  painful  points  determined  by  Schuh  and  Valleix, 
the  following  may  be  mentioned,  in  the  present  connection  : 
a,  the  point  of  exit  of  the  infraorbital  nerve  from  the  infraorbital 
canal ;  6,  the  gum  of  the  upper  jaw  in  which  the  anterior,  mid- 
dle or  posterior  dental  nerves  are  the  seat  of  the  affection  ; 
c,  the  condyle  of  the  jaw,  when  the  pain  appears  to  be  located 
in  the  inferior  dental  nerve,  in  most  cases,  and  particularly  at 
the  point  of  its  entrance  into  the  dental  canal ;  d,  the  point  of 
exit  of  the  mental  nerve  on  the  chin. 

The  reflex  i^henomena  have  reference  both  to  the  motory  and 
secretory  fibres.  The  motor  symptoms  are  manifested,  chiefly, 
in  the  facial  muscles,  by  clonic  or  tonic  contractions.  According 
to  the  statements  of  Schuh,  with  intensely  painful  neuralgias, 
especially  when  the  cause  is  seated  within  the  cranial  cavity,  it 
also  happens  that,  not  only  the  muscles  of  the  face  and  eyes,  but 
nearly  all  the  muscles  of  the  body  are  thrown  into  a  state  of 
tonic  contraction,  so  that  the  patients  appear  rigid  and  immov- 
able, like  a  statue,  and  retain,  perfectly,  the  position  in  which 
they  were  at  the  moment  of  the  attack.  The  rigidity  of  the 
muscles  continues  until  the  paroxysm  of  pain  ceases.  Very 
rare  cases  have  been  observed  where  the  sensibility  of  certain 
points  was  so  acute  that  the  sudden  and  unexpected  contact  of 
anything  would  even  cause  the  patient  to  fall,  with  loss  of  con- 
sciousness and  convulsions. 


432  NEUROSES. 

The  affection  of  the  secretory  apparatus  is  manifested  upon 
the  surface  of  the  skin,  by  perspiration  in  the  region  of  the 
face,  and  an  increased  secretion,  subsequent  to  the  paroxysm, 
from  the  mucous  membrane  and  corresponding  glands,  as  the 
mucous,  salivary,  and  lachrymal  glands. 

Irritation  of  the  fibres  of  the  sympathetic  is  effected  through 
the  ganglions  Avithin  the  territory  of  the  trifacial  nerve,  namely, 
in  the  eye  through  the  ciliary  ganglion,  in  the  ear  through  the 
spheno-palatine  and  otic  ganglions,  in  the  secretory  apparatus 
on  the  floor  of  the  oral  cavity,  through  the  submaxillary 
ganglion.* 

It  is  necessary  to  refer  in  this  connection  to  a  special  exciting 
cause  of  facial  yieuralgia,  which,  in  my  opinion,  is  of  great  im- 
portance, namely,  the  extraction  of  teeth.  Schuli  observes  that 
it  is  particularly  noticeable,  that  very  many  patients  date  the 
origin  of  their  suffering  from  the  time  of  the  extraction  of  one 
or  several  decayed  teeth.  Although  he  suggests  caution  in  ac- 
cepting this  statement,  he  is  convinced,  nevertheless,  from  ex- 
tensive observations  upon  the  subject,  that  the  extraction  of  un- 
sound teeth,  especially  if  the  operation  is  performed  with  vio- 
lence or  is  repeated  at  one  sitting,  sometimes  is  the  cause  of 
neuralgias,  in  consequence  of  the  stretching  and  laceration  of 
the  delicate  nervous  filaments.  Many  well-informed  persons, 
who  were  accustomed  to  observe,  carefully,  their  sensations  and 
conditions  of  body  and  have  stated  confidently  and  positively 
that  they  were  able  to  distinguish  a  difference  between  the  tooth- 
ache which  they  felt  before,  from  the  slight  and  soon  increasing 

*  Through  irritation  of  the  sympathetic  nerve  the  uterus  is  broug"ht  into 
close  relation  with  the  teeth.  It  is  a  well-known  fact  that  pains  of  the  teeth 
often  occur  during  pregnancy  as  well  as  during  certain  inflammatory  atfec- 
tions  of  the  uterus,  and  cases  have  been  recorded  of  recovery  from  pains  and 
symptoms  of  disease  in  the  uterus  upon  the  extraction  of  one  or  more  teeth. 
In  a  large  number  of  cases  of  diseases  of  the  uterus,  the  teeth  are  seriously 
affected  by  caries.  Out  of  more  than  twenty-five  patients  suffering  from 
uterine  disease,  in  a  hospital  for  diseases  of  women  in  this  city,  examination 
of  their  mouths  showed  extensive  caries  of  the  teeth  in  all  but  one.  This  is 
a  subject  which  needs  thorough  investigation.  At  the  present  time,  our 
knowledge  is  so  limited  that  we  cannot  say  with  much  assurance  how  much 
the  teeth  and  the  uterus  aflect  each  other  in  the  reciprocal  action  of  condi- 
tions of  disease. — T.  B.  H, 


FACIAL    NEURALGIA    CAUSED    BY    EXTRACTION.        433 

neuralgia  wliich  occurred  a  few  hours  after  the  extraction  of  the 
tooth,  would  admit  no  other  exciting  cause  than  the  one  in 
question. 

If  we  consider  the  fact  that,  in  connection  with  caries  of  the 
teeth,  the  pulp  becomes  inflamed  and  entire  bundles  of  nerves 
manifest  evidences  of  degeneration,  while,  in  the  neuritic  pro- 
cess, which  occurs  in  neuralgia,  single  nerve-tubes  only  are 
affected  in  the  manner  already  described,  there  are  grounds,  in 
my  opinion,  for  the  assertion  that  the  two  processes  present 
anatomical  differences,  and  that  the  darting  pains  in  facial  neu- 
ralgia are  due  to  the  affection  of  the  separate  nerve-tubes. 

If  we  consider,  also,  that,  after  amputation  of  the  limbs,  sensi- 
tive nerve-tubes  sometimes  grow  in  large  numbers  from  the  sur- 
faces of  the  transversely-divided  nerves,  as  I  proved*  in  the 
year  1855,  it  is  probable,  that  an  analogous  process  occurs  in 
nerves  which  have  been  lacerated  in  the  extraction  of  teeth ; 
indeed  we  have  an  intimation  of  such  an  occurrence  in  the  pains 
in  the  sockets  from  which  teeth  have  been  extracted.  If,  noAv, 
a  predisposition  (Diathese)  to  the  development  of  new-formations 
of  nerves  of  this  description  exists  in  an  individual,  or  if,  in  con- 
sequence of  unskilful  extraction,  the  nervous  branches  which 
supply  the  teeth  are  not  separated  from  their  attachments  to 
the  main  stems,  but  are  badly  bruised  and  crushed,  and  the 
main  stem  itself  is  injured  more  or  less,  the  condition  of  irrita- 
tion which  is  produced  in  the  nerves  may,  sometimes,  induce  a 
proliferation  of  the  sensitive  fibres.  Actual  proof  of  this  sup- 
position remains  to  be  established  in  the  future.  With  regard 
to  the  diathesis,  we  may  call  to  mind  that  such  a  condition  has 
been  established  for  the  new-formations  of  dentine,  cement, 
periosteum  of  the  root  and  gum,  and  we  may,  upon  good 
grounds,  speak  of  a  progressive  new-formation,  t.  e.,  of  one 
which  extends  to  the  adjacent  tooth.  It  is  quite  reasonable, 
therefore,  to  assume  a  diathesis  for  the  proliferation  of  nerves 
after  their  laceration.  Premising  this,  it  is  quite  easy  to  un- 
derstand that  the  extraction  of  teeth  for  the  relief  of  facial  neu- 
ralgias only  aggravates  the  evil. 

*  Zeitschr.  d.  Gesellsch.  d.  Aerzte  zu  Wien. 
28 


434  NEUROSES. 

From  this  point  of  view,  I  regard  the  suggestion  of  Dobbelin* 
as  a  fortunate  one,  namely,  to  substitute  another  operative  treat- 
ment in  place  of  the  resection,  which  necessitates  deep  incisions 
and,  indeed,  affords  relief  for  a  few  months  only,  when  the  focus 
of  irritation  is  located  in  the  nerves  of  single  teeth.  He  cites  a 
series  of  cases  which  occurred  in  his  practice,  where  he  produced 
a  complete  cure  of  facial  neuralgia,  particularly  of  the  infra- 
orbital nerve,  by  exposing  the  pulp-cavity  with  a  trephine  and 
killing  the  nerves  of  the  root  in  all  non-carious  bicuspids  and 
molars,  and  by  killing  the  nerves  of  the  coronal  and  radical 
pulp  in  cases  in  which  perforating  caries  had  occurred.  One 
case  is  particularly  instructive,  where  the  infraorbital  nerve 
together  with  a  portion  of  the  upper  jaw  around  the  infraorbital 
foramen  had  been  removed,  but  without  a  successful  result  ;  he 
trephined  all  the  bicuspids  and  molars  which  remained  in  the 
jaw,  and  effected  a  cure. 

With  the  multiplicity  of  the  above-mentioned  foci  of  irritation 
of  the  dental  nerves  (comp.  p.  427)  and  the  indefiniteness  of 
the  painful  sensations,  it  frequently  happens  that  nothing  is  left 
in  the  way  of  treatment,  but  to  destroy,  experimentally,  the 
supposed  focus  of  irritation  in  an  affected  tooth  or  in  a  root.  The 
result,  then,  will  confirm  or  disprove  the  correctness  of  the  sup- 
position. It  is  self-evident  that,  in  an  isolated  case  in  which  the 
experiment  is  attended  with  a  successful  result,  we  must  be  on 
our  guard  and  avoid  the  false  conclusion,  'post  hoc,  ergo  propter 
hoc.  If,  however,  in  a  series  of  observations  we  find  that  the 
same  favorable  effect  ensued  in  equivalent  cases,  or  a  complete 
and  permanent  cessation  of  the  symptoms  followed  the  removal 
of  the  centre  of  irritation  in  individual  cases,  or  a  notable  abate- 
ment was  observable,  then  in  one  case  the  supposition  is  raised 
to  a  certainty,  and  in  the  other  it  is  reduced  to  a  mere  proba- 
bility, or  the  latter,  even,  may  be  questionable. 

When  the  nerves  of  the  gum  are  subjected  to  a  severe  irrita- 
tion by  the  advancing  crowns  during  the  first  dentition,  pain  of 
a  radiating  character  is  developed  in  the  sensitive  organism  of 
the  child,  reflex  phenomena  occur  in  the  form  of  convulsions  or 

*  Deutsche  Viertelj.  f.  Z.,  18G8. 


ABSTRACT    OF    CASES.  435 

epileptiform  paroxysms  ;  in  a  series  of  well  observed  cases,  these 
symptoms  disappeared  immediately  after  the  division  of  the  irri- 
tated nerves  of  the  gum  with  the  lancet.  Hence,  in  these  cases, 
the  centre  of  irritation  without  doubt  was  located  within  the 
gum.  Upon  pure  theoretical  grounds,  also,  the  above-men- 
tioned consecutive  irritations  of  the  central  nervous  system  must 
have  their  origin  in  the  irritated  nerves  of  the  gum. 

The  recorded  observations  of  many  observers,  also,  shoAv  that 
anomalies  in  the  second  dentition,  in  children  of  a  nervous  tem- 
perament, sometimes  occasion  neuralgias,  convulsions  and  epilep- 
tiform paroxysms,  and,  therefore,  it  is  evident  that,  in  such  cases, 
the  physician  should  not  neglect  to  examine  the  condition  of  the 
teeth.  An  unusually  difficult  eruption  of  the  wisdom  teeth  may 
be  the  cause  of  similar  symptoms  and  even  of  mental  aberra- 
tion. 

The  following  series  of  cases,  which  I  have  endeavored  to  make 
quite  extensive  in  consequence  of  the  great  importance  of  the 
subject,  will  serve  to  illustrate  the  preceding  observations  with 
reference  to  the  focus  of  irritation,  when  it  is  situated  in  the 
dental  nerves. 

Breithaupt*  reported  a  case  of  prosopalgia  caused  by  an  im- 
pacted canine  in  the  upper  jaw.  The  affection  was  removed  by 
the  extraction  of  the  tooth.  Forgetf  observed  a  case  of  neu- 
ralgia which  was  occasioned  by  a  wisdom  tooth  in  the  axis  of 
the  jaw.  IIesse|  met  with  a  case  of  neuralgic  pains  in  the  lower 
jaw,  induced  by  a  wisdom  tooth  which  was  imbedded  within  the 
jaw  in  an  oblique  position,  with  its  crown  directed  towards  the 
molar  in  front  of  it.  The  molar  was  removed,  the  pain  ceased 
and  the  patient  soon  recovered.  F.  H.  Thomson§  observed  a 
case  of  facial  neuralgia  resulting  from  the  concrescence  of  the 
roots  of  the  wisdom  and  second  molar  tooth,  which  prevented 
the  descent  of  the  former.  Esquirol  reports  the  case  of  a  woman 
who  recovered  from  insanity  after  a  crucial  incision  was  made 
in  the  gum  in  order  to  promote  the  eruption  of  the  wisdom 
tooth.     Ashburner  relates  the  case  of  a  young  man,  seventeen 

*  Deutsche  Viertelj.  f.  Zahnh.,  1861.     f  ^es  Anomalies  dentaires,  1859. 
X  Gazette  des  Hopitaux,  1856.  g  Dental  Eeview,  18G0. 


436  NEUROSES. 

ycavs  of  age,  who  was  afflicted  with  delirium,  destructive  mania 
and  delusions.  Incisions  were  made  in  the  gum  covering  the 
wisdom  teeth,  and  recovery  ensued  in  a  week.  Forget  cites  a 
case  of  severe  dental  neuralgia,  caused  by  a  wisdom  tooth,  the 
crown  of  which  Avas  inclined  anteriorly  and  exerted  a  strong 
pressure  upon  the  second  molar.  The  affection  led  the  patient 
to  commit  suicide.  He  jumped  from  the  upper  story  of  a  house, 
tetanus  succeeded  and,  finally,  death.  Hancock  observed  a  re- 
covery from  trismus  and  pain  under  the  right  ear,  after  the  ex- 
traction of  the  first  molar.  Dbbbelin  cites  a  case  where  tetanus 
occurred  simultaneously  with  the  extraction  of  a  tooth.  Ben- 
sow*  had  under  his  treatment  a  young  man  suffering  from  very 
severe  neuralgia  in  the  upper  first  molar  which,  evidently,  was 
free  from  any  disease.  Extraction  proved  to  be  useless,  and 
the  patient  died  on  the  fourth  day  after  the  operation.  Exami- 
nation after  death  showed  nothing  worthy  of  observation  in  the 
mouth ;  the  brain  was  healthy  ;  at  the  origin  of  the  fifth  nerve, 
a  collection  of  pus,  the  size  of  a  mustard-seed,  was  found.  I  am 
inclined  to  question  whether  this  was  not  the  result  of  the  un- 
avoidable injury  to  the  nerves  of  this  tooth  in  extraction,  which 
were  in  a  condition  of  hypertesthesia.f 


*  British  Journal  of  Dental  Science,  1867. 

f  J.  Tomes  (System  of  Dental  Surgery)  states  that  two  cases  came  under 
his  notice  in  which  epilepsy  was  consequent  upon  diseased  teeth,  the  most 
prominent  feature  being  exostosis  of  the  roots.  "  A  lad,  a  farm  laborer,  from 
"Windsor,  was  admitted  into  the  hospital  for  epilepsy.  The  usual  remedies 
were  tried  for  six  weeks  without  effect.  His  mouth  was  then  examined,  and 
the  molar  teeth  of  the  lower  jaw  were  found  to  be  much  decayed,  and  of 
some  of  these  the  fangs  only  remained.  He  did  not  complain  of  pain  in  the 
diseased  teeth  or  in  the  jaw.  The  decayed  teeth  were,  however,  removed,  and 
the  fangs  of  each  were  found  to  be  enlarged  and  bulbous  from  exostosis. 
During  the  eighteen  months  that  succeeded  the  removal  of  the  diseased 
teeth,  he  had  not  suffered  from  a  single  fit,  though  for  many  weelvs  previous 
to  the  operation  he  had  two  or  three  per  day.  This  is  a  case  of  singular  in- 
terest, inasmuch  as  there  was  no  complication  of  maladies,  and  lience  there 
could  be  no  doubt  as  to  the  cause  of  the  disease,  seeing  that  it  immediately 
subsided  when  the  teeth  were  removed  ;  and  it  is  further  useful  in  showing 
that  a  sufficient  source  of  local  irritation  to  induce  functional  derangement 
may  exist  without  pain  being  felt  in  the  part  where  the  irritation  is  applied." 

"A  similar  but  less  marlved  case  occurred  shortly  afterwards,  in  the  person 


ABSTRACT    OF    CASES.  437 

Fox*  relates  the  follo>ving  case  :  "  The  patient  was  a  young 
ladj,  twenty  years  of  age  :  for  more  than  a  year  she  had  suf- 
fered from  deepseated  pain  in  the  face,  and  in  the  teeth  and 
gums.  The  pain  gradually  extended  to  all  the  teeth,  and  one 
by  one  all  those  of  the  lower  jaw,  with  the  exception  of  the 
four  incisors,  were  removed.  During  this  time  every  kind  of 
medical  treatment  had  been  resorted  to,  but  without  affording 
her  any  alleviation  to  her  sufferings.  At  the  time  the  patient 
consulted  Mr.  Fox,  she  was  only  able  to  take  fluid  nutriment, 
for  the  teeth  of  the  upper  jaAv  Avere  so  tender  that  the  slightest 
touch  caused  extreme  pain.  There  was  a  constant  flow  of  saliva 
from  the  mouth,  and  the  palpebrre  of  one  eye  had  been  closed 
for  nearly  two  months  [and  Avhen  opened  the  sight  of  the  eye  was 
affected].  The  most  painful  tooth  was  extracted.  This  was 
the  first  molar  of  the  upper  jaw,  situated  under  the  eye,  the 
palpebrpe  of  which  had  become  closed.  The  fangs  of  the  tooth 
were  much  enlarged  ;  its  removal  was  attended  with  great  bene- 
fit, and  two  days  after,  the  affected  eye  could  be  opened.  This 
only  afforded  partial  relief,  and  eventually  all  the  teeth  were 
removed,  when  the  patient  Avas  at  length  relieved  from  her  suf- 
ferings." This  case,  probably,  was  one  of  a  progressive  prolif- 
eration of  cement,  where  the  process  advances  from  one  tooth 
to  another,  and,  in  my  opinion,  it  would  have  been  a  suitable 
case  for  the  method  of  treatment  recommended  by  Dobbelin 
(comp.  p.  434).  Thomsonf  describes  a  case  of  prosopalgia  re- 
sulting from  exostoses  of  the  roots  of  the  wisdom  teeth. 

of  a  policeniiin.  He  had  fits,  which  were  greatly  relieved  by  the  removal  of 
an  inferior  wisdom  tooth,  the  subject  of  caries  and  of  exostosis." 

With  reference  to  the  first  case,  an  essential  point  in  the  argument  for  the 
stated  source  of  local  irritation  is  wanting,  in  my  o[)inion,  namely,  that  it 
was  possible  to  bring  on  the  fits  by  irritation  of  the  decayed  teeth.  It  is, 
also,  to  be  borne  in  mind  that,  as  Kosenthal  observes  (1.  c,  p.  311),  particular 
caution  is  enjoined,  both  in  respect  of  the  prognosis  and  the  estimation  of 
the  results  of  treatment,  by  the  frequency  of  recurrences,  even  after  a  remis- 
sion of  the  paroxysms  for  several  years.  Again,  no  little  importance  is  to  be 
attached  to  the  fact  that  the  regulation  of  the  diet,  which  obtains  in  the  hos- 
pital, exercised  a  beneficial  influence  in  diminishing  the  frequency  of  the  fits 
with  the  two  epileptics. 

*   Vide  Hulme's  Lectures,  Dental  Eeview,  1862. 

f  Glasgow  Med.  Journal,  1867. 


438  NEUROSES. 

Hilton*  reports  the  case  of  a  man  whose  hair,  upon  the  left 
temporal  region,  became  gray,  as  a  result  of  a  carious  affection 
of  a  lower  molar.  He  suffered  from  neuralgia  in  the  left  side 
of  the  face,  for  the  relief  of  which  he  was  treated  in  various 
ways  without  success.  He  wore  a  wig,  as  the  rest  of  his  hair 
was  black.  The  carious,  lower  second  molar  was  extracted  and 
the  neuralgia  disappeared  almost  entirely.  It  is  not  stated 
whether  the  hair  upon  the  temple  became  black  again,  since  the 
patient  was  not  seen  again. 

Von  Stellwagf  regards  it  as  probable  that  irritations  in  remote 
portions  of  the  trigeminus  nerve  may  be  transmitted  through 
the  ciliary  system  to  the  nervous  apparatus  which  serves  for  the 
reception  of  luminous  impressions,  occasion  an  increased  excita- 
tion in  this  and,  by  producing  hyperemia  and  inflammation, 
give  rise  to  amaurosis  (amaurosis  trifacialis  of  Beer).  "  It  is  a 
well-known  fact,"  he  says,  "that  it  is,  by  no  means,  an  uncom- 
mon occurrence  for  intense  irritations  of  one  or  another  division 
of  the  trifacial  nerve  to  lead  to  hypercesthesia,  and  later  to 
hypercemia  and  inflammation  in  the  territory  of  the  ciliary 
nerves.''  "  Hypertesthesia  of  the  ciliary  nerves|  may  also  be  in- 
duced by  exfoliation  of  an  alveolar  process,  abscesses  in  the 
roots  of  a  tooth,  and  the  impaction  of  foreign  bodies  in  an 
alveolus."  He  cites  the  following  cases  in  his  notes.  Galen- 
zowski  cured  a  complete  amaurosis  which  occurred  in  conjunc- 
tion with  a  most  violent,  intermittent  neuralgia  in  the  temporal 
region,  face  and,  especially,  in  the  eye,  by  the  extraction  of  a  cari- 
ous bicuspid  upon  the  root  of  which  there  was  a  splinter  of  wood 
that  had  produced  an  irritation  of  the  dental  nerves.  (I  once 
found  a  splinter  of  wood  which  entirely  filled  the  root-canal  of 
a  carious  tooth  and,  evidently,  was  a  fragment  of  a  tooth-pick.) 
Teirlink  relates  a  case  where  an  impacted  fragment  of  a  tooth 
in  the  upper  jaw  of  a  woman  occasioned  frequent  attacks  of 
odontalgia,  which  were  accompanied,  at  different  times,  by  in- 
tense pain  in  the  eyes,  intolerance  of  light,  a  profuse  secretion 


*  Lancet,  1861. 

f  Ophthalmologie  vom  naturwiss.  Standpunkt,  ii,  p.  657. 

X  Ibid.,  p.  321. 


ABSTRACT    OF    CASES.  439 

of  tears,  dimness  of  vision,  contraction  and  immobility  of  the 
pupil.  All  treatment  Avas  unsuccessful  until  the  fragment  was 
removed,  when  the  pain  ceased  immediately.  Hay  observed  a 
case  where  a  man,  who  had  overworked  himself  at  a  fire,  suffered 
from  an  excessive  intolerance  of  light  Avhich  continued  even  in  a 
dark  room.  The  uncomfortable  sensation  seemed  to  start  from 
one  of  the  upper  incisors.  Tapping  upon  this  tooth  with  a  key 
produced  most  violent,  twinging  pains.  Upon  the  extraction  of 
this  tooth,  an  abscess  was  found  in  the  root.  Recovery  ensued 
after  the  removal  of  the  tooth,  and  six  years  afterwards  there 
had  been  no  recurrence  of  the  affection.* 

Hutchinsonf  observes  that  far  too  little  attention  is  given  to 
the  condition  of  the  teeth  as  the  possible  cause  of  functional  or 
nutritive  derangements  in  the  globe  of  the  eye  or  in  the  cerebral 
centres  of  vision,  and  remarks  especially  upon  the  importance 
of  taking  advantage  of  every  opportunity  to  clear  up  the  subject 
of  the  possibility  of  the  evil  effects  of  stumps  of  teeth  which  are 
left  in  the  jaws. 

In  confirmation  of  this  opinion,  I  will  cite  the  following  cases. 
Dr.  EmraeuchJ  suffered  for  fourteen  years  from  notable  conges-* 
tions  in  the  region  of  one  eye,  profuse  secretion  of  tears  and  in- 
tolerance of  light.  These  symptoms  were  increased  by  slight 
errors  of  diet.  He  found  a  carious  tooth  upon  the  side  corres- 
ponding with  the  affected  eye.  Almost  immediately  after  the 
extraction  of  this  tooth,  the  symptoms  referable  to  the  eye  be- 
gan to  abate  and,  in  a  short  time,  they  disappeared  entirely. 
Teirlink  mentions  tAvo  cases.  A  first  upper  bicuspid  was  ex- 
tracted from  the  jaw  of  a  young  man,  for  the  relief  of  very 
severe  toothache;  the  patient  stated  that  he  suffered  from  quite 
severe  pains  in  the  eye  upon  the  same  side,  and,  on  another 
day,  he  came  with  a  complaint  that  his  sight  was  affected.  The 
pupil  was  very  much  dilated.  Extract  of  opium  and  opium 
ointment  were  inserted  in  the  alveolus  and  effected  a  contraction 
of  the  pupil  and  restoration  of  sight.     A  woman  complained  of 

*  Comp.  also  von  Stellwag's  Lehrbiicli  der  Augenheilkunde,  4  Aufl.,  p. 
854. 

f  Ophthalmic  Review,  1866.  J  Dublin  Medical  Free  Press. 


440  NEUROSES. 

defective  vision  and  excessive  secretion  of  tears.  After  the 
extraction  of  a  carious  root,  the  sight  Avas  restored  gradually 
and  the  excessive  lachrymal  secretion  ceased.  Hancock*  re- 
ported three  cases.  A  lad,  eleven  years  of  age,  on  Avaking 
from  sleep  one  month  previously,  found  that  he  was  entirely 
blind.  Previously  he  had  nothing  the  matter  -with  his  eyes,  and 
when  he  went  to  bed  on  the  preceding  night  he  could  see  dis- 
tinctly. Treatment  had  availed  nothing.  The  pupils  were 
dilated,  the  iris  was  motionless  and  did  not  respond  to  the  ex- 
citation of  light.  He  was  unable  to  distinguish  light  from 
darkness.  Upon  examination  of  the  teeth,  Hancock  found 
them  tightl}'  wedged  and  crowded  together.  Two  permanent 
bicuspids  and  four  milk  molars  were  extracted;  the  same  even- 
ing, the  boy  could  distinguish  light  from  darkness,  and  in  the 
following  morning  he  was  able  to  make  out  objects.  From  this 
time  the  boy's  sight  improved,  and  eleven  days  after  the  opera- 
tion, he  was  discharged  well.  A  man  came  to  the  Westminster 
Ophthalmic  Hospital  on  account  of  amaurosis  of  the  right  eye, 
which  had  existed  for  eight  months  and  came  on  suddenly.  He 
•could  distinguish  between  light  and  darkness;  the  pupil  was 
dilated  and  fixed.  Medical  treatment  did  no  good.  The  second 
upper  molar  on  the  right  side  was  found  to  be  diseased,  and  it 
was  extracted.  Two  days  afterwards,  he  was  able  to  distinguish 
objects,  although  imperfectly.  A  few  days  later,  he  returned 
home,  cured.  A  patient,  twenty-two  years  of  age,  had  been 
affected  with  strabismus  for  three  years.  A  ptosis  had  existed 
about  a  fortnight.  The  left  eye  was  closed.  The  affection 
came  on  suddenly,  without  pain,  either  in  the  head  or  eye. 
After  treatment  had  been  employed  without  success  for  nine 
days,  two  carious  teeth  were  found  in  the  left  side  of  the  upper 
jaw,  which  were  not  painful.  The  affection  had  assumed  an  in- 
termittent character.  In  the  morning,  the  eye  was  open; 
towards  noon,  the  lid  dropped  down  and,  at  evening,  it  resumed 
its  original  position.  In  four  days  after  the  administration  of 
quinine,  the  ptosis  was  cured,  the  strabismus  was  improved,  so 
that,  in  fact,  no  operation  was  done.     Kemptonf  observed  a 

*  Lancet,  1859.  f  Dental  Review,  1861. 


ABSTRACT    OF    CASES.  441 

case,  Avhere  a  woman  had  suffered  for  a  fortnio-ht  from  severe 
pains  in  the  right  temporal  region,  which  extended  over  the 
nape  of  the  neck,  sometimes  affected  the  side  of  the  face,  and 
were  accompanied  by  shooting  pains  in  the  globe  of  the  eye. 
Cold  applications  within  the  mouth  and  externally  alleviated 
her  suffering.  There  was  no  toothache.  The  lower  right  wis- 
dom tooth  was  extensively  carious,  and  the  gum  was  swollen. 
During  the  extraction,  she  experienced  a  severe  pain  across  the 
right  side  of  the  head,  which  lasted  a  few  seconds,  but  no  pain 
in  the  locality  from  which  the  tooth  was  removed.  The  neuralo^ia 
disappeared. 

De  Witt,*  in  a  man  who  stated  that  he  had  been  nearly  blind 
in  the  right  eye  for  twelve  years,  so  that  he  could  merely  dis- 
tinguish light  from  darkness,  found  a  cavity  filled  with  white 
metal  in  the  first  bicuspid,  and  a  fistulous  opening  in  its  alveolus. 
Upon  the  removal  of  the  filling,  a  foul-smelling,  sanious  matter 
escaped  from  the  cavity  of  the  tooth.  Three  weeks  later,  when 
the  right  eye  had  recovered  so  that  it  performed  its  functions 
nearly  as  well  as  the  other,  the  sensitiveness  of  the  gum  re- 
turned and,  at  the  same  time,  the  vision  again  became  affected. 
The  tooth  was  then  extracted,  and  the  amaurosis  disappeared 
immediately  (?).  Six  days  afterwards,  the  patient  was  able  to 
see  Avith  the  right  eye  as  well  as  with  the  left,  except  that  small 
objects  were  not  clearly  recognizable.  De  Witt  remarks  that 
the  amaurosis  had  its  origin  in  an  irritation  of  the  fifth  nerve. 

Cases,  also,  are  recorded  which  indicate  the  efi'ect  of  diseased 
teeth  upon  the  hearing.  Certain  sounds,  such  as  a  creaking 
noise,  produce  sensations  in  the  teeth.  Carious  teeth  sometimes 
occasion  paroxysmal  pains  in  the  ear.  The  following  case  came 
under  the  observation  of  Harvey.  A  man,  twenty-two  years  of 
age,  suffered  for  three  years'  from  attacks  of  neuralgia  in  the 
ear,  which,  occasionally,  were  accompanied  by  a  foul-smelling 
discharge  from  the  external  meatus  and  lasted  several  hours. 
The  most  intense  pain  was  felt  in  the  direction  of  a  carious 
Avisdom  tooth.  This  was  extracted  and  the  neuralgia  was 
cured.     Vautierf  reported  a  case  of  facial  neuralgia  and  deaf- 

*  American  Journal  of  Medical  Sciences,  1868. 
f  Gazette  des  Hopitaux,  1860. 


442  NEUROSES. 

ness,  which  was  cured  by  the  extraction  of  an  upper  wisdom 
tooth. 

J;imes  Salter,  in  his  instructive  article  upon  nervous  affections 
induced  by  diseases  of  the  permanent  teeth,*  expresses  the 
opinion  that,  next  to  the  branches  of  the  trigeminus,  the  cervical 
and  brachial  plexuses  are  most  frequently  affected  by  an  irrita- 
tion of  the  teeth.     He  cites  a  series  of  instructive  cases. 

Thomas  Bellf  reported  two  cases  in  point.  In  one,  the  patient 
had  suffered  for  a  year  from  irregular  paroxysms  of  pain  which 
was  felt,  at  first,  in  the  ear  and,  afterwards,  extended  across  the 
neck  and  shoulder  and  along  the  arm,  producing  impairment  of 
motion  in  the  hand  and  fingers.  Bell  ascertained  that,  two 
years  previous  to  that  time,  the  lower  second  molar  had  been 
broken  off,  in  an  attempt  to  extract  it,  and  the  roots  were  still 
in  the  jaw  ;  the  anterior  one  had  emerged,  partially,  from  the 
socket  and  lay  upon  the  gum,  in  an  oblique  position  ;  the  pos- 
terior root  Avas  still  firmly  imbedded  and,  evidently,  occasioned 
considerable  irritation  in  the  surrounding  parts  ;  pressure  upon 
this  root  increased  the  pain  which,  in  a  measure,  assumed  the 
character  of  the  paroxysmal  pains  from  which  the  patient  had 
suffered  so  long.  The  stumps  Avere  removed  and  the  paroxysms 
did  not  return.  In  a  second  case,  there  was  slight  impairment 
of  motion  in  the  right  arm,  with  occasional  pain  and  the  peculiar 
sensation  of  formication  Avhich  is  felt  Avhen  pressure  is  exerted 
upon  a  nerve.  Finally,  the  patient  noticed  that  a  paroxysm 
was  accompanied  by  an  acute  pain  in  the  lower  second  molar 
upon  the  same  side.  This  fact  led  to  a  careful  observation  of 
the  succeeding  attack.  Bell  became  satisfied  that  the  contact 
of  a  sharp  instrument  with  this  tooth  occasioned  a  return  of  the 
sensation  in  the  arm.  The  tooth  was  extracted  and  a  complete 
cure  ensued,  although  not  immediately. 

F.  H.  Thomson^  mentions  three  cases  of  facial  neuralgia, 
consequent  upon  caries  of  the  wall  of  the  antrum. 

These  cases  are  sufficient  to  show  that  facial  neuralffias  and 


*  Guy's  Hospital  Reports,  xiii,  1868. 

t  Anat.  Phys.  and  Path,  of  the  Teeth,  2d  ed. 

X  Dental  Review,  18G0. 


ANESTHESIA    OF    THE    DENTAL    NERVES.  443 

various  affections  of  the  eye,  ear,  the  cervical  and  brachial 
plexuses  not  infrequently  have  their  origin  in  an  irritation  in 
the  teeth,  and  that  dentists,  and  surgeons,  especially,  should  not 
neglect  to  make  a  careful  examination  of  the  teeth  in  connection 
with  these  aff'ections ;  the  experience  and  knoAvledge  of  an  edu- 
cated dentist,  of  course,  is  requisite  for  this  purpose  ;  the  mere 
extraction  of  a  tooth  at  random  is  of  no  avail. 

Anaesthesia  of  separate  teeth  occurs  in  connection  with 
atrophy  of  the  dental  nerves,  consequent  upon  previous  inflam- 
mations, new-formations,  within  the  pulp  or  outside  of  the 
same,  folloAving  chronic  inflammation  of  the  root-membrane,  ab- 
scesses at  the  extremities  of  roots,  &c.  Anaesthesia  of  one  or 
another  side  of  a  set  of  teeth  has  its  origin  in  the  trunks  of  the 
dental  nerves  or  in  more  central  localities.  The  possibility  of 
the  existence  of  new-formations  ought  to  be  taken  into  account 
as  a  cause  of  this  affection.  When  apoplexy,  tabes,  hysteria, 
tumors  of  the  pons  Varolii  and  the  posterior  lobes  of  the  cere- 
brum, which  encroach  upon  the  territory  of  the  trigeminus 
(second  and  third  divisions),  give  rise  to  anaesthesia  of  parts  cor- 
responding to  the  anatomical  distribution  of  the  nerves,  as  shown 
by  Ch.  Voigt,  then  the  teeth  and  the  gums,*  also,  become  de- 
prived of  their  sensibility.  Rosenthalf  cites  a  case,  which  came 
under  his  observation,  where,  in  connection  with  anaesthesia  of 
the  second  division  of  the  trigeminus  on  the  right  side,  the  upper 
teeth  and  gums  were  entirely  insensible,  while  the  lower  teeth 
and  the  floor  of  the  oral  cavity  manifested  the  normal  sensibility. 
At  the  autopsy,  a  new-formation,  as  large  as  a  nut,  was  found  in 
the  left  half  of  the  pons  Varolii. 

*  Rosenthal,  op.  cit.,  p.  500.  f  Ibid.,  p.  77. 


ALPHABETICAL    INDEX. 


PAGE 

Abscesses  in  the  alveoli, 

216 

coronal  dentine  of  human  teeth,  . 

187 

dentine  of  animals'  teeth,     . 

187 

gums, 

198 

jaws, 

225 

maxillary  periosteum,  . 

222 

P"lp,      

.      177,  179 

186 

root-membrane,    .... 

210 

root,  the  cause  of  affections  of  the  cil 

iary 

nerves. 

438 

tusks  of  elephants,  new-formation  of 

osseous  substance 

with, 

304 

Absorbent  organ, 

79 

Adenomata, 

821 

Adhesion  of  all  the  teeth  impossible. 

154 

the  pulp  to  the  dentine, 

241 

Alveolar  abscess, 

216 

arteries,  injection  of  the, 

60 

process,  affection  of  the  ciliary  nerves  caused  by 

exfoliations 

of  the, 

438 

arch  of  the,         .... 

23 

enostosis  of  the,  .... 

331 

epulis  of  the,       .... 

.      322 

347 

exostosis  of  the. 

.      228 

327 

hypertrophy  of  the,    . 

228 

interstitial  development  of  bone  in 

exostoses  of  the. 

329 

necrosis  of  the,    .... 

.      222 

226 

new-formations  of  the. 

322 

of  the  lower  jaw. 

25 

of  the  upper  jaw, 

22 

osteomata  of  the, 

.      228 

327 

purulent  infiltration  into  the,    . 

217 

results  of  fractures  of  the,  . 

223 

senile  resorption  of  the. 

. 

266 

Alveoli,  abscesses  in  the, 

216 

cicatrization  of  the,  ..... 

258 

description  of  the,     ..... 

22,  25 

446 


ALPHABETICAL    INDEX. 


Alveoli,  fracture  of  the, 223.  263 

growth  of  the  coronal,       ........  70 

partial  resorption  of  the,  previous  to  the  eruption  of  the  teeth,  71 
resorption  of  the,  in  connection  with  inflammation  of  the  root- 
membrane,     ..........  213 

resorption  of  the,  after  extraction  of  teeth,       ....  259 

senile,         ...........  2.3.5 

septa  of  the, 23 

Amaurosis  consequent  upon  dental  caries,      .....      439,  441 
the  impaction  of  foreign  bodies  in  the  teeth 

and  jaws, 438 

the  malposition  of  teeth,    ....  440 

trifacialis,      ..........  438 

Anassthesia  of  the  teeth,           .........  443 

Anatomical  changes  in  the  nerves  and  ganglions  in  neuralgias,    .         .  426 
Aneurism  of  the  superior  palatine  artery,  to  be  distinguished  from  an 

abscess,      ............  218 

Angiomata  of  the  gums,          .........  319 

Angle  of  the  lower  jaw,  peripheral  and  pericellular  resorption  of  the,  .  269 

senile  changes  in  the,       .....  269 

Anomalies  of  the  secretions,   .........  354 

Antimony,  effects  upon  the  root-membrane,  from  the  use  of,         .          .  215 

Antrum  of  Highmore,     ..........  24 

catarrhal  inflammation  of  the,          ......  229 

cj^sts  of  the,       ..........  351 

dropsy  of  the,    .         .         .         .       ■ 229,  231 

empyema  of  the,        .........  229 

entozoa  in  the,  ..........  3.53 

facial  neuralgia,  caused  by  caries  of  the  wall  of  the,         .         .  442 

fistula  of  the, 219,  352 

foreign  bodies  in  the,         ........  280 

inflammation  of  the  membranes  of  the,  a  sequel  of 
root-membrane,      ...... 

polypi  of  the  mucous  membrane  of  the,    . 
Appearances  presented  by  carious  cement,     . 

dentine,     . 
enamel. 
Arsenic,  effects  of,  upon  the  root-membrane. 
Articular  eminence  of  the  temporal  bone,  senile  flattening  o 
Articulation  of  the  lower  jaw , 
Artificial  caries. 


teeth,  caries  of, 
Atony  of  the  gums, 
Atrophies,       .... 
Atrophy,  eccentric,  of  Rokitansky, 
net-like,  of  the  pulp, 
of  the  maxilhe, 

maxillary  periosteum,  . 


f  the, 


that  of  the 

229 
352 
391 
384 
376 
215 
270 
.  26 
374,  375,  407 

4,  376,  406,  414 
255 
232 
2.58 
238 
257 
257 


ALPHABETICAL    INDEX. 


447 


Ati'ophy  of  the  pulp,       ...... 

resulting  from  iiiflamniation, 
root-membrane,    .... 

socket,  ...... 

primary  or  senile,  ..... 

secondary  or  consecutive, 

senile,  of  the  gums,         .... 

Axial  torsions  of  the  crowns,  .... 


PAGE 

232 
191 

2-55 
2.58 
232 
232 
2.:)4 
132 


Bacteria, 19.5,  211,  358,  407 

Bicuspids,  description  of  the,  .........       34 

Blending  of  adjacent  teeth, 147 

distinguished  from  twin-formation,    .         .     149 

milk  teeth, 149 

Bloodves.sels  of  the  pulp  in  inflammation,  changes  in  the,     .         .         .     180 

Bone,  caries  of,  distinguished  from  that  of  teeth,  .         .       367,  370,  374,  4'Jl 

interstit'ial  development  of,  .        .         .         .         .  78,  92.  276,  306,  329 

growth  of,  in  the  jaws,        ......       92 


resorption  of,  in  the  jaws,  . 
Brachial  plexus  of  nerves,  affections  of  the,  consequent  upon 
of  the  dental  nerves,         ...... 

Buccal  fistula,  ........ 

BUhlmann's  fibres,  ....... 


Calcifications,  combination  of,  with  new-formations  of  dent 
of  the  pulp,      ...... 

consequent  upon  inflammation, 
senile  root-membrane,  . 
Cancer,  cystoid-gelatinous,  of  the  upper  jaw, 
epithelial,  of  the  gums, 
jaws, 
fibrous,  of  the  gums,  .... 

jaws,   .... 

gelatinous,  of  the  jaws, 
medullary,  of  the  gums,    . 
jaws,      . 
melanotic,  of  the  dental  sac, 

intermaxillary  bone, 
of  the  root-membrane, 
Canine  teeth,  description  of  the,     . 
Cantharides,  effects  of,  upon  the  root-membrane, 
Carcinoma,  see  Cancer. 
Caries  of  the  teeth,  ..... 

acute  or  moist,  . 
appearances  presented  by  the  cement  in, 
dentine  in, 
enamel  in, 


.       92 
ations 

.     442 

.     219 

3-57,  372 


.  296 

191,  233 

.  191 

.  2.5 

.  351 

.  320 

.  349 

.  3-51 

.  351 

.  351 

.  321 

.  350 

.  350 

.  350 

.  317 

.  34 

.  215 

.  367 
7  et  jmssim 

.  391 

.  384 

.  376 


448 


ALPHABETICAL    INDEX. 


PAGE 

Caries,  artificial, 374.  375,  407 

carbonacea, ..........     416,  425 

cartilaginous  softening  of  dentine  in,  .         .         .         .     S87  et  passim 

change  in  the  color  of  the  hair  consequent  upon,         .         .         .     438 
chronic,         .........     387  et  passim 

of  the  dentine,  ......     389  et  passim 

consolidation  of  the  dentinal  fibrils  in,        .         .         .      323,386,413 

deposits  of  pigment  in  the  enamel  in, 378 

diminished  consistence  of  the  enamel  in, 379 

transkicency  of  the  dentine  in,    .......     384 

discoloration  of  the  dentine  in,    .......     384 

extension  of,  to  the  root,      ........     392 

frequency  of,  see  Frequency  of  Caries, 397 

historical  sketch  of, 368 

increased  transluceney  of  the  surrounding  dentine  in,  .  .  386 
increased  transparency  of  the  enamel  in,  .....  378 
interna,         ....         191,  369,  371,  872,  374,  413,  421,  422 

localities  of, 393 

neuralgic  aflections  consequent  upon,  .         .  .     438  ct  passim 

of  artificial  teeth, 374,376,406,414 

pivoted  teeth,  ..........     406 

reinserted  human  teeth,  ......      404,  406,  414 

teeth  made  from  hippopotamus-ivorj-,    .....     406 

signification  of,       .......         .     367 

distinguished  from  that  of  bone,    .         .       367,  370,  374,  421 
the  different  kinds  of  teeth,     .......     393 

permanent  teeth,  ......     394 

milk  teeth,  .........     396 

roots  of  permanent  teeth, .......     396 

teeth  of  animals,        ........     410 

wall  of  the  antrum,  the  cause  of  facial  neuralgias,   .         .     442 

sicca, 390,  423,  425 

symmetrical  afiection  of  corresponding  teeth  with,     .         .         .     369 
theories  of,   ..........         .     411 

undermining,  of  the  dentine,        .......     389 

enamel,        .......     382 

white, 408 

Carious  teeth,  amaurosis  consequent  upon,     .....      439,  441 

deafness  consequent  upon,         ......     441 

effects  of,  upon  the  rest  of  the  body,         .         .     403  et  passim 
neuralgic  aflections  of  the  ear  consequent  ujion,      .         .     441 
ptosis  consequent  upon,    ......      437,  440 

Cartilaginous  softening  of  carious  dentine,     ....     S87  ct  passini 

Cases  illustrating  neuroses  depending  upon  aflections  of  the  teeth,         .     435 
Castor  oil,  eflects  of,  uj-on  the  root-membrane,       .....     215 

Catarrhal  inflammation  of  the  antrum,  .......     229 

ffums,      .......     192 


ALPHABETICAL    INDEX.  449 

PAGE 

Cavity  of  the  mouth,  bony  framework  of  the,         .....  21 

Cement, 51 

caries  of  the, 391,  421 

changes  in  the,  in  connection  with  the  process  of  shedding  the 

teeth, 77 

development  of  the,   .........  69 

hypertrophy  of  the,   .........  271 

in  grooved  teeth,        .........  149 

interstitial  hypertrophy  of  the, 276 

resorption  of  hypertrophic, 274 

junction  of  the,  with  the  dentine,      ......  53 

neuralgias  consequent  upon  hypertrophy  of  the,       .         .         .  272 

new-formations  of,     .......         .     272,  312 

perforating  resorption  of  the,     .......  274 

peripheral-concentric  hypertrophy  of  the,         ....  276 

resorption  of  hypertrophic,       .....  278 

progressive  proliferation  of  the,         ......  437 

resorption  of  senile,    .........  247 

senile  thickening  of  the, 244 

Cervical  plexus  of  nerves,  affections  of  the,  consequent  upon  irritations 

of  the  dental  nerves, 442 

Changes  in  the  jaws  during  the  second  dentition,  .....  91 

form  of  teeth,  indicative  of  syphilis,       ....  146 

temporary  and  permanent  dental  arches  compared,        .  95 

Chondromata  of  the  jaws,        .         .         . 839 

Cicatrization  of  the  socket,      .........  258 

variation  in  the  position  of  adjacent  teeth  during,    .         .  263 

Ciliary  nerves,  affections  of  the,  consequent  upon  abscesses  of  the  root,  438 
affections  of  the,  consequent  upon  exfoliations  of  the 

alveolar  process,  ........  438 

affections  of  the,  consequent  upon  irritation  of  the  tri- 
facial nerve,          ........  438 

affections   of  the,  consequent   upon   the   impaction  of 

foreign  bodies  in  the  teeth  and  jaws,  ....  438 

Classification  of  malformations  of  the  teeth,  ......  157 

the  teeth, 30 

Cleavage  of  the  teeth, 29,  376 

Cleft-palate, 89 

Coalition  of  the  roots,     .........     147,  152 

Coating  upon  the  teeth;  ..........  357 

living  organisms  in  the,     .....  357 

Colloid  deposits  in  the  pulp,   .........  237 

Concrescence  of  roots,     .........     147,  152 

facial  neuralgia  consequent  upon  the,  .         .         .  435 

Condyle  of  the  lower  jaw,  senile  wasting  of  the,     .....  270 

Condyloid  or  nodular  enlargements  upon  the  extremities  of  roots,     138,  139 

Conical  teeth, 100,  102 

29 


450 


ALPHABETICAL    INDEX. 


Consecutive  atrophy,  ..... 
Consolidation  of  the  dentinal  fibrils  in  caries, 
Convulsions  during  the  first  dentition,   . 

in  connection  with  anomalies  in  the 
Copper,  efi'ects  of,  upon  the  root-membrane, . 
Coronoid  process  of  the  lower  jaw,  senile  wasting 
Cracks  in  the  enamel,     ..... 
Cretefactions  in  the  pulp,        .... 
Croton  oil,  effects  of,  upon  the  root-membrane. 
Croupous  inflammation  of  the  gums, 
Crowns,  axial  torsions  of  the, 
flexions  of  the,  . 
surfaces  produced  by  friction  upon  the, 
and  roots,  dwarfish,  . 
Cuticle  of  the  enamel,     . 
Cystoid-gelatinous  cancer  of  the  upper  j 
Cysto-myxoma  of  the  jaws,     . 
Cysto-sarcoma  adenoides, 
of  the  jaws, 
Cysts,  dentigerous, 

of  the  antrum, 

jaws, 
ovarian,  containing  rudimentary  teeth, 
Cytoblastions  in  the  root-membrane 


of  th 


Deafness  consequent  upon  caries 

Deciduous  teeth,  see  Temporary  Teeth. 

Defective  formation  of  the  crowns  and  roots. 

Defectively  developed  enamel,  histology  of,    . 

Defects  in  the  enamel,  causes  of,     .....         .     142  and 

wedge-shaped,  upon  the  facial  surface  of  the  neck 
Deficiency  of  milk  teeth, 

permanent  teeth, 
Degeneration  of  the  parenchyma  of  the  embryonic  pulp 
pulp  into  a  soft,  greasy  mass 

Density  of  the  teeth, 

Dental  arches,  comparison  of  the  changes  in  the  temporary  and  per- 
manent,   . 
canal  in  old  age, 


d  den 


cap,     .... 
cartilage,     . 
groove, 

posterior, 

membrane,  inflammation  of  the  external, 
pulp,  see  Pulp. 

ridge, 

sac,  development  of  the,     . 


373, 

tition. 


PAGE 

232 
413 
434 
435 
215 
270 
0,  168,  376 
.  234 
.  215 
.  196 
.  132 
.  130 
.  247 
.  157 
51,  69 
.  351 
.  349 
.  344 
.  343 
.  172 
.  351 
.  331 
.  172 
59,  317 


45,  244, 


441 

139 
143 
Note 
253 
107 
104 
170 
241 
28 

95 
242 

69 
420 

61 

85 
205 

61 
64 


ALPHABETICAL    INDEX 


451 


Dental  sac,  melanotic  cancer  of  the, 
primary  stage  of  the,  . 
sarcomatous  proliferation  o 
DenticolsB,        .... 
Dentinal  canals  or  tubes, 
cells, 

inversion  of  the  layer  of. 
fibres,       .... 

consolidation  of  the,  in 
germ,  development  of  the, 

primary  stage  of  the, 

globules,  .... 

sheaths,  of  E.  Neumann, 

Dentigerous  cysts,  .... 

Dentine, ...... 


f  the. 


canes, 


of. 


s  portions 


of  carioui 


abscesses  in  the, 

adhesion  of  the  pulp  to  the, 

appearances  presented  by  carious 

cartilaginous  softening  of  the  carious, 

chronic  caries  of  the, 

combination  of  calcifications  with  new-formations 

concentrically  laminated  new-formation 

diminished  translucency  of  carious, 

direction  of  the  development  of  the, 

discoloration  of  carious,  . 

duration  of  the  development  of  the, 

growth  of  the  radical  portion  of  the, 

hardness  of  the,        .... 

increased  translucency  of  the  contiguou 

in  grooved  teeth, 

interglobular  spaces  of  the, 

interstitial  development  of, 

intertubular  tissue  of, 

junction  of  the  cement  with  the, 

enamel  with  the, 

pulp  with  the, 
new-formations  of,  . 
of  repair,  .... 

of  animals'  teeth,  abscesses  in  the, 
of  the  tusks  of  elephants,  new-formation  of  osseous  substance 

with  abscesses  in  the, 
red  color  of  the,  with  infiammation  of  the  pulp, 
secondary, 

senile,       .... 
sensitiveness  of  the, 

theories  concerning  the  mode  of  development  of  the, 
undermining  caries  of  the,       ..... 


PAGE 

.  350 
.  62 
.  346 
357,  358 
.  43 
.  54 
.  295 
.  44 
373,  386,  413 
.  65 
.  61 
.  45 
44 
.  172 
.   43 


187 

241 

384 

387  et  passim, 

389  et  passim 

of,  .    .  296 

289 

384 

66 

384 

66 

70 

29 

386 

145 

45 

294 

45 

58 

50 

54 

286  et  passim 


289 
187 


188,  304 

183,  370 

289 

242 

56 

68 

389 


452 


ALPHABETICAL    INDEX. 


Dentition,  see  First,  Second,  and  Third  Dentition. 

Development  of  the  cement, 

dentine, 

enamel,  ..... 

germs  of  the  first  and  second 
molars,, 
interstitial,  of  bone, 

dentine,    . 
of  malformations,  mode  of  the, 
the  teeth,     ..... 

wisdom  teeth, 
Digitalis,  effects  of,  upon  the  root-membrane, 
Dilaceration,  ........ 

Diminution  in  the  size  of  the  pulp-cavity  and  dental  canal 
Diphtheritic  inflammation  of  the  gums, 
Diphtberitis,  ........ 

Displacement,  retention  of  teeth  without, 
Distinctions  between  the  milk  and  permanent  teeth 
Double  or  twin-malformations,       .... 

Dropsy  of  the  antrum, 

Durability  of  the  enamel,  ..... 
Dwarfish  malformations  of  the  crowns  and  roots, 
Dyscrasic  periostitis  of  the  jaws,    .... 


Ear,  neuralgic  aflTections  of  the,  consequent  upon  carie 
Edentulous  jaws,    ...... 

Effects  of  carious  teeth  upon  the  rest  of  the  body 

various  substances  upon  the,  . 
Elasticity  of  the  teeth,  .... 

Elephants'  teeth,  musket-balls  in,  . 

Empyema  of  the  antrum. 

Enamel,  ....... 

appearances  presented  by  carious 

cap,  appearances  presented  by  the  carious, 
detachment  of  the,  . 

causes  of  defects  in  the,    . 

cells, 

cracks  or  fissures  in  the,  . 

deposits  of  pigment  in  carious, 

direction  of  the  development  of  the, 

durability  of  the,     . 

fibres,       ..... 

germ,       ..... 

germs  of  permanent  teeth  with  a  single  root, 
the  first  and  second  permanent  mol 
wisdom  teeth, 

hardness  of  the, 


permanent 


69 
68 
64 

86 

8,  92,  276,  306,  329 

294 

155 

60 

86 
215 
133 
242 
205 
197 
127 

40 
170 
231 

49 
157 
224 


in  old  age 


22 


441 

226 

403 

215 

30 

301 

229 

46 

376 

379 

47 

142  and  Note 
47,  63 
30,  168,  370 
378 
66 
49 
47 
61 
66 
86 
86 
29 


ALPHABETICAL    INDEX. 


453 


Enamel,  histological  appearances  of  defectively  developed, 
irregular  distribution  of  the,  . 
junction  of  the,  with  the  dentine,   . 
membrane  (Nasmyth's),  . 

appearance  of  the  cai'ious, 
in  old  age, 
new-formations  of,  . 
nodules,    ...... 

of  grooved  teeth,      .... 

organ,       ...... 

prisms,     ...... 

property  of  double  refraction  of  the, 
senile,       ...... 

striiB  of  the,     ..... 

theories  concerning  the  mode  of  development  of  the, 
thickness  of  the,      .... 

undermining  caries  of  the, 
Enchondromata  of  the  jaws,  .... 

Enostoses  of  the  alveolar  process,  . 

jaws, 

Entozoa  in  the  antrum,  .... 

Epilepsy  consequent  upon  exostosis  of  the  roots. 
Epileptiform  paroxysms  in  association  with  anomalies 
dentition,         ....... 

Epileptiform  paroxysms  during  the  first  dentition. 
Epithelial  cancer  of  the  gums, 
jaws, 
Epulis,    .         .         .... 

fibromatosa, 
sarcomatosa, 

varieties  of,    . 
Erosion  {Note),       .... 

Eruption  of  the  milk  teeth,    . 

intervals  between  the, 
first  permanent  molars, 
permanent  teeth,  . 
second  permanent  molars, 
wisdom  teeth, 
Exanthemata,  infiammation  of  the  gums  in 
Exanthematous  periostitis  of  the  jaws,  . 
Excentric  atrophy  of  Kokitansky, . 
Exostoses  of  the  cement, 

cement,  prosopalgia  consequent  upon, 
alveolar  process,  . 

interstitial  developm 
roots,  epilepsy  consequent  upon. 
Experiments  with  different  substances  upon  the  teeth, 


the, 


the  second 


51,  69 


325 

325 

143 

73 

75 

76 

82 

85 

86 

195 

224 

258 

272,  312 

.     315 

228,  327 

ent  of  bone  in,     329 

436 

407 


PAGE 

143 

141 

50 

,  165 

381 

247 

296 

134 

144 

62 

47 

50 

246 

48 

64 

47 

382 

339 

331 

337 

353 

436 


435 
434 
320 
349 
322,  347 
323 


454 


ALPHABETICAL    INDEX. 


the  opera- 


30,  168, 


Extension  of  caries  to  the  roots,     ........ 

Extraction  of  teeth,  a  special  cause  of  facial  neuralgias. 

Facial  neuralgia  consequent  upon  caries  of  the  wall  of  the  antrum,     . 

imbedded  teeth, 
exostoses,  . 
the  concrescence  of  roots, 

Fatty  degeneration  of  the  pulp, 

resulting  from  inflammation 
of  milk  teeth, 
Fibro-chondroma  of  the  jaws,        ..... 
Fibromata  of  the  gums,  ....... 

jaws, 

Fibrous  cancer  of  the  gums,  ...... 

jaws, 

Filling,  importance  of  new-formations  in  connection  with 
tion  of,      .         .         ... 

First  dentition,        ........ 

convulsions  during  the,  . 
diseases  occasioned  by  the, 
epileptiform  paroxysms  during  the, 
reflex  symptoms  during  the,  . 

Fissures  or  cracks  in  the  enamel, 

Fistula,  buccal, 

in  the  gum,         ....... 

of  the  antrum,  ....... 

salivary,     ........ 

Flexions  and  torsions  of  the  crowns  and  roots, 

of  the  roots,      ....... 

Foreign  bodies  in  the  antrum,         ..... 

teeth,  the  cause  of  affections  of  the  ciliary  nerves, 
Formation,  defective,  of  the  crowns  and  roots, 
of  the  teeth,  irregularities  in  the. 
Fractured  teeth,      ........ 

cases  of,        .....         . 

conditions  necessary  for  the  union  of, 
union  of,  longitudinally. 
Fracture  of  the  alveolus,         ...... 

Fragilitas  vitrea, 

Frequency  of  caries 

influence  of  age  upon  the,     . 

diseases  of  the  general  sy; 

the, 
family  upon  the, 
food  upon  the,   . 
locality  upon  the, 
occupations  upon  the, 


stem 


219, 
219, 


223, 


upon 


400, 


PAGE 

392 
432 

442 
435 
315 
435 
232 
191 
233 
339 
319 
340 
351 
351 

300 
73 
434 
199 
435 
434 
876 
219 
198 
352 
221 
130 
132 
230 
438 
139 
98 
307 
307 
309 
311 
253 
258 
397 
399 

413 
400 
402 
400 
402 


ALPHABETICAL    INDEX. 


455 


Frequency  of  caries,  influence  of  popular  customs  upon  the, 

race  upon  the,     . 
sex  upon  the, 

the  use  of  tobacco  upon  the, 
in  the  difl"erent  kinds  of  teeth, 

Fusion  of  teeth,  see  Blending. 


Ganglions  and  nerves,  anatomical  changes  in  the,  in  neuralgias, 
Gangrene  of  the  mouth  (Noma),    . 

pulp,  moist  and  dry, 
Gangrenous  degeneration  of  the  root-membr 
Gelatinous  cancer  of  the  jaws, 
tumors  of  the  jaws, 

Glands,  mucous, 

salivary, 

secretion  of  the  salivary,  . 
Globular  masses  of  the  dentine. 
Globules,  dentinal,  .... 

Gold,  eflfects  of,  upon  the  root-membrane. 
Groove,  dental,        ..... 

posterior  dental. 
Grooved  teeth,  peculiarities  of  the  tissues  in 
Growth  of  the  jaws,        .... 
direction  of  the,     . 
lower  jaw,  measurements  of  the. 
"  Gumboil,"    .... 
Gums, 

abscesses  in  the,    . 

action  of  lead  upon  the 

acute  or  inflammatory  oedema  of  the, 

angiomata  of  the, 

atony  of  the, 

atrophy,  senile,  of  the, 

bloodvessels  of  the, 

cancer  of  the, 

epithelial  cancer  of  the, 

epithelium  of  the, 

fibromata  of  the,  . 

fibrous  cancer  of  the, 

fistulse  in  the, 

glands  of  the, 

hypertrophy  of  the, 

inflammations  of  the,  see  Inflammation. 

in  mercurial  salivation, 

lancing  the,  . 

medullary  cancer  of  the, 

nerves  of  the, 


456 


ALPHABETICAL    INDEX. 


Gums,  new-formations  of  the, 
papillae  of  the, 
papilloma  of  the, 
sarcoma  of  the,     . 
scorbutic, 
secretion  of  the,   . 
senile  atrophy  of  the, 
vascular  tumors  of  the 


PAGE 

319 
57 
281,  319 
320 
255 
355 
254 
319 


Hair,  change  in  the  color  of  the,  resulting  from  caries, 
Hardness,  Moh's  scale  of, 
of  the  dentine, 
enamel, 
Hard  tissues  of  the  teeth, 
Harelip,  .... 
Hearing  affected  by  diseased  teeth. 
Herpetic  (?)  inflammation  of  the  gums, 
History  of  caries,    .... 
Horny  character  of  senile  dentine, 
Hydrargyriasis,       .... 
Hydrocephalus,  teeth  in  a  case  of  congenital 

Hydrops  antri, 

Hypertrophies, 

Hypertrophic  cement,  interstitial  resorption  of, 
perforating  resorption  of, 
peripheral  resorption  of, 
root-membrane,  pigment  deposits  in  the 
Hypertrophy  of  the  alveolar  process,     . 

cement,  .... 

neuralgias  caused  by, 
interstitial, 
peripheral  concentric 
gums,     .... 
root-membrane. 

Incisors,  description  of  the,    .... 

Inflammations,        ...... 

Inflammation  of  the  gums,    .... 

during  the  first  dentition, 

during  the  second  dentition 

catarrhal,     . 

causes  of, 

croupous, 

diphtheritic, 

herpetic  (?), 

in  syphilis,  . 

in  the  exanthemata, 


488 
•29 
29 
29 
43 
89 
441 
195 
368 
242 
205 
148 
229,  231,  331 
271 
274 
274 
273 
279 
228 
271 
272 
276 
276 
279 
277 

32 
176 
192 
200 
204 
192 
193 
196 
205 
195 
195 
195 


ALPHABETICAL    INDEX. 


457 


Inflammation  of  the  gums,  modified  by  individual  peculiarities, 
phlegmonous,       .... 
rare  sequels  of,     . 
suppurative,  .... 

the  origin  of  ulceration, 
mucous  membrane  and  periosteum  of  the  antrum 

consequent  upon  that  of  the  root-membrane, 
nasal  mucous  membrane  and   periosteum,  conse 
quent  upon  that  of  the  root-membrane, 

pulp> 

acute,     ..... 

changes  in  the  bloodvessels  in, 

nerves  in, 
chronic,  .... 

circumscribed,        ...... 

terminating  in  acute  or  moist  grangrene,     . 
general,  ....... 

leading  to  that  of  the  root-membrane,  . 
leads  to  atrophy,    ...... 

calcifications,     .         . 

fatty  degenerations,  .... 

redness  in,       . 

suppurative,    .....      177,  179 

the  cause  of  the  reddish  color  of  dentine, 
increased  volume  in,       . 
root-membrane,       .         .         . 

changes  in  the  hard  tissues  of  the 

root  in,      . 
acute,    . 
chronic, 

consequent  upon  that  of  the 
etiology  of,    . 
in  animals,    . 

resorption  of  the  alveolus  in 
resulting  in  gangrene,  . 
stages  of,        .         .         . 
Inflammatory  or  acute  oedema  of  the  gums,  .... 

Injection  of  the  alveolar  arteries,   ...... 

Insanity,  resulting  from  the  diflicult  eruption  of  a  wisdom  tooth 
Interalveolar  bloodvessels,      ....... 

nerves,      ........ 

Interglobular  spaces  of  the  dentine,       ..... 

Intermaxillary  bone,  melanotic  cancer  of  the, 

Interstitial  development  of  bone,  .         .         .         .78,  92,  2' 

dentine,       ..... 

facets  from  the  friction  of  contiguous  crowns,     . 
growth  of  bone  in  the  jaws,  .... 


PAGE 

194 
198 
201 
198 
194 

229 

.  228 

.  176 

.   176,  179 

.  ISO 

.  181 

176,  179,  186 

.  178 

182 

178 

192 

191 

191 

191 

178 

186 

183 

178 

204 


.  212 
205,  206 
205,  208 

pulp,  192 
.  213 
.  222 
.  213 
.  211 
.  205 
.  198 
.  60 
.  435 
.  59 
.  60 
45 
.  350 

6,  306,  329 
.  294 
.  252 
.   92 


458 


ALPHABETICAL    INDEX. 


PAGE 

Interstitial  hj-portrophy  of  cement, 276 

resorption  of  bone  in  the  jaws,     ..... 

92 

hypertrophic  cement,       .... 

274 

Intertubular  tissue  of  the  dentine, 

45 

Intervals  between  the  eruption  of  the  milk  teeth,  . 

75 

Inversion  of  the  layer  of  dentinal  cells, 

295 

Iodine,  effects  of,  upon  the  root-membrane, 

215 

Irregularities  in  the  arrangement  of  entire  sets  of  teeth, 

108 

distribution  of  the  enamel,     .... 

141 

formation  of  teeth, 

98 

number  of  permanent  teeth,  . 

99 

position  of  the  milk  teeth,      .... 

121 

permanent  teeth,     . 

112 

separate  permanent  teeth  imbedded  within 

the  jaw, 

122 

size  of  the  milk  teeth,     ..... 

99 

permanent  teeth,  .... 

98 

structure  of  the  teeth, 

130 

Jaw,  see  Upper  and  Lower  Jaw,  and  Maxilla. 

Jaws,  abscesses  in  the,    ..........     226 

atrophy  of  the, 

.     257 

cancer  of  the, 

.     349 

changes  in  the,  during  the  second  dentition 

) 

.       91 

arch  of  the. 

.       95 

chondromata  of  the,     .... 

.     339 

cystoid-gelatinous  cancer  of  the  upper, 

.     351 

cysto-myxoma  of  the,  .... 

.     349 

sarcoma  of  the,     .... 

.     343 

cysts  of  the, 

.     .331 

direction  of  the  growth  of  the, 

.       89 

edentulous,  ..... 

.     266 

enchondromata  of  the, 

.     339 

enostoses  in  the, 

.     337 

epithelial  cancer  of  the. 

.     349 

fibro-chondromata  of  the,     . 

.     339 

fibroma  of  the, 

.     340 

fibrous  cancer  of  the,     .... 

.     351 

gelatinous  cancer  of  the. 

.     351 

tumors  of  the, 

.     348 

growth  of  the, 

.       88 

interstitial  growth  of  bone  in  the, 

.       92 

medullary  cancer  of  the. 

.     350 

melanotic  cancer  of  the, 

.     350 

mj'^eloid  sarcoma  of  the, 

.     347 

myxomata  of  the,          .... 

.     348 

necrosis  of  the,  during  dentition. 

223 

ALPHABETICAL    INDEX. 


459 


Jaws,  osteoid-choudroma  of  the,     . 

osteophytes  upon  the,   . 

osteo-carcinoma  of  the, 
sarcoma  of  the,    . 

periosteal  sarcoma  of  the,     . 

periostitis  of  the,  see  Periostitis. 

purulent  infiltration  of  the,  . 

relative  growth  of  the, 

sarcomata  of  the, 

senile  wasting  of  the,    . 

wolf's, 

Juga  alveolaria,      .... 

Lancing  the  gums, 
Leptothrix  buccalis, 

reaction  of,  with  iodine  and  acids. 
Longitudinal  fracture  through  the  crown  and  root,  union  of  a, 
Lower  jaw,  see  Jaw. 

articulation  of  the,        ...... 

description  of  the,         ...... 

direction  of  the  growth  of  the,     .... 

measurements,  showing  the  relative  growth  of  the 

movements  of  the,         ...... 

ossification  of  the,         ...... 

periostitis  of  the,  see  Periostitis. 

senile  changes  in  the,  ...... 


357 


PAGE 

.  339 

.  335 

.  351 

.  347 

.  347 

.  225 

.  92 

.  343 

.  257 

.  89 

.  23 

.  199 

et  passim 

.  358 

.  311 

.  26 

.  24 

.  89 

.  92 

.  26 

.  89 

.  269 


Malformations  of  the  teeth, .         .     154 

classification  of  the,         .......     157 

dwarfish,  of  the  crowns  and  roots,  .....     157 

general,  of  the  crown  of  a  molar,  with  undeveloped 
roots,  in  connection  with  the  deeply  imbedded  crown 
of  a  wisdom  tooth,       .......     158 

mode  of  the  development  of  the,     .....     155 

monstrous,  of  the  coronal  with  a  well-formed  radical 
portion,        .........     158 

of  the  teeth  of  animals,  .......     167 

Malposition  of  the  teeth,  amaurosis  consequent  upon,    ....     440 

neuralgias  consequent  upon,  .         .         .      435,  436 
Masseter  muscles,  senile  wasting  of  the,  ......     269 

Mastication,  actions  of  the  muscles  in, 27,270 

movements  in,    .         .         .         .         .         .         .         .       27,  270 

muscles  of,  .         .         -         .         ■         •         •         •         •         .27 

Maxillae,  see  Jaws. 

Maxillary  periosteum,  abscesses  in  the, 222 

atrophy  of  the, 257 


460  ALPHABETICAL    INDEX. 

PAGE 

Maxillary  periosteum,  inflammatory  afi'ections  of  the,  from  those  of 

the  pulp  or  root-membrane,      ......  222 

sinus,     ...........  24 

Measurements  showing  the  relative  growth  of  the  jaws,         ...  93 

Medullary  cancer  of  the  gums,        ........  321 

jaws, 850 

Melanotic  cancer  of  the  dental  sac,         .......  350 

intermaxillary  bone,         .....  350 

Membrane,  Nasmyth's  enamel, 51,  69,  165 

of  the  root,  see  Koot-Membrane. 

Meningo-encephalitis,  consequent  upon  the  extraction  of  a  tooth,        .  223 

Mental  aberration,  consequent  upon  the  second  dentition,     .         .         .  435 

foramen,     ...........  24 

Mercurial  salivation,  gums  in,       . .         .         .         .         .         .         .         .  195 

Mercury,  effects  of,  upon  the  root-membrane, 215 

Micrococcus,    ............  357 

Milk  teeth,  see  Temporary  Teeth. 

Mixed  saliva,  see  Saliva,          .........  355 

Moh's  scale  of  hardness,           .........  29 

Molars,  description  of  the,       .........  35 

development  of  the  enamel  germs  of  the  first  and  second  per- 
manent, ...........  86 

eruption  of  the  first  permanent,         ......  76 

second  permanent, 85 

Monstrous  malformation  of  the  crown  with  well-formed  roots,     .         .158 

outgrowth  of  dentine  and  cement  upon  the  root,  .         .         .  169 

Mouth,  bony  framework  of  the  cavity  of  the,         .....  21 

gangrene  of  the  (Noma), 199,  201 

the  flat, 108 

grinning  (Fletschenmund),          ......  109 

negro  (os  -^thiopum),          .......  108 

senile  (os  senile),  .         .         .         .         .         .         .         .110 

Movements  of  the  lower  jaw,           ........  26 

Mucin, 354 

Mucor, 194,  415 

Mucous  glands, 354 

membrane  of  the   antrum,  inflammation  of  the,  consequent 

upon  that  of  the  root-membrane,  ......  229 

membrane  of  the  antrum,  polypi  of  the,    .....  352 

mouth,  new-formations  of  the,       .         .         .  321 
nasal  cavitj'^,  inflammation  of  the,  consequent 

upon  that  of  the  root-membrane,        .         .  228 

secretion  of  the,        .......  355 

Mucus, 354 

Multilocular  ovarian  cysts  containing  imperfectly  developed  teeth,       .  172 

Musket-balls  in  the  teeth  of  elephants, 301 

Myeloid  sarcomata  of  the  jaws, 347 


ALPHABETICAL    INDEX.  461 

PAGE 

Myeloplaxes, 59,  317 

Myxomata  of  the  jaws,   ..........  348 

Nasal  cavity,  inflammation  of  the  mucous  membrane  and  periosteum 

of  the,  consequent  upon  that  of  the  root-membrane,        .         .         .  228 

Nasmyth's  membrane,    ........         51,  69,  165 

Necrosis  of  the  alveolar  process,     .......     222,  226 

cement,  consequent   upon   inflammation   of  the   root- 
membrane,  212 

jaw,  during  dentition, 223 

Nerves  and  ganglions  in  neuralgias,  anatomical  changes  in  the,  .         .  426 

of  the  pulp  in  inflammation,  changes  in  the,     ....  181 

resection  of,  for  the  relief  of  neuroses,        .....  430 

Net-like  atrophy  of  the  pulp,          ........  238 

Neuralgia  in  a  molar,  resulting  in  death,        ......  436 

Neuralgias,  anatomical  changes  in  the  nerves  and  ganglions  in,    .         .  426 

clinical  phenomena  of,         ......         .  430 

consequent  upon  caries, 438  ei  jyassim 

Dobbelin's  operation  for  the  relief  of,          ....  434 

exciting  causes  of,        .......         .  427 

extraction  of  teeth,  a  special  cause  of,          ....  432 

foci  of  irritation  in,     .         .         .         .         .         .         .         .  427 

irradiation  of  the  pain  in,    ......         .  429 

occasioned  by  anomalies  in  the  second  dentition,        .         .  435 

impacted  teeth, 435 

painful  points  in, 431 

reflex  phenomena  in,  .......         .  431 

resection  of  nerves  in,           .......  430 

Neuritic  process  [Neuritis], 427,  429 

Neuroses,  see  Neuralgias,        .........  426 

consequent  upon  afl'ections  of  the  teeth,  abstract  of  cases  of,  435 

New-formations, 284 

importance  of,  in  connection  with  the  operation  of  till- 
ing,    300 

in  the  teeth  of  animals,         ......  297 

literature  of, 286 

of  cement,     .........  312 

dentine, 286 

combination  of,  with  calcifications,      .         .  296 

concentrically  laminated,     ....  289 

enamel, 296 

osseous  substance  with  abscess  in  elephants'  ivory, 

188,  804 

the  alveolar  process,          ......  289 

gums,          ........  319 

hard  dental  tissues,     ......  286 

oral  mucous  membrane,      .....  321 

pulp, 191,  285 


462 


ALPHABETICAL    INDEX. 


PAGE 

New-formations  of  the  root-membrane, 316 

osteo-dentinal,       ......      293  et  passim 

physiological  or  pathological  signification  of,       .         .     299 
progressive,  .........     434 

dentinal, 300 

Nitrous  acid  salt  in  the  saliva,        ........     355 

Nodules  of  enamel,  ..........     134 

Nodular  or  condyloid  enlargements  at  the  extremities  of  roots,     .     138,  139 
Noma, 199,  201 


Oblique  fractures  of  the  crown,  exposure  of  the  pulp  in, 

roots. 
Odontalgia  nervosa  ex  carie,  . 
Odontoblasts,  ...... 

Odontolithus,  ...... 

Odontomata  (iVo^e),         .... 

(Edema  of  the  gums,  acute  or  inflammatory, 
Oidium  albicans,     ..... 

Opium,  eff"ects  of,  upon  the  root-membrane, 
Organ  adamantiiic'e,        \         .         .         . 
Os  iEthiopum,         .         ... 

senile,  ...... 

Ossification  of  the  lower  jaw, 
upper  jaw, 

senile  root-membrane, 
Osteoid  chondromata  of  the  jaws,   . 
Osteo-carcinoma  of  the  jaws, 

dentine,  ..... 

in  the  teeth  of  animals,     . 
odontomata,  ..... 

sarcomata  of  the  jaws,  . 
Osteomata  of  the  cement, 

prosopalgia  consequent  upon 
alveolar  process, . 

interstitial 
Osteophytes  upon  the  jaws,     . 
Osteopsathyrosis  of  Lobstein, 
Ostitis,     ....... 

Ovarian  cysts,  teeth  in,  . 


Papillte  of  the  gums, 
Papilloma  of  the  gums,  . 
Parulis,  .... 
Penicillium  glaucum. 
Perforating  caries, . 

resorption  of  hypertrophic  cement, 
Pericellular  resorption  of  the  angle  of  the  lower  jaw, 


development  of  bone 
20: 


19 


358, 


311 
309 
177 

54 
361 
155 
198 
406 
215 
163 
108 
110 

89 


255 
339 
351 

46,  293  et  passim 
.     297 
169,  316 
169,  343 
.  312 
.  315 
228,  327 
in,  .  329 
2,  228,  335 
258 
367 
172 


281, 


57 
319 
198 
357 

176  et  passi7)i 
274 
269 


ALPHABETICAL    INDEX. 


463 


chan 


Periodontitis,  ........ 

Periosteal  sarcoma  of  the  jaws,       ..... 

Periosteum  of  the  root,  see  Root-Membrane. 
Periostitis  of  the  alveoh\r  process,  consequent  upon  caries, 
jaw,  during  the  first  dentition,    . 
second  dentition, 
dyscrasic, 
exanthematous, 
rheumatic,  . 
specific, 
traumatic,    . 
lower  jaw,  symptoms  of, 
upper  jaw,  symptoms  of, 
Peripheral-concentric  hypertrophy  of  the  cement, 
resorption  of  hypertrophic  cement, 

the  angle  of  the  lower  jaw. 
Permanent  and  temporary  dental  arches,  comparison  of  the 

the, 

teeth,  arrangement  of  the,    . 
caries  of  the  diiFerent, 
carious  roots  of  the,     . 
deficiency  of  the, 
♦  description  of  the, 
eruption  of  the,   . 
imbedded  within  the  jaw,  irregular  position  of, 
irregularities  in  the  arrangement  of  entire  sets  of, 
irregularities  in  the  number  of, 

position  of  separate, 
size  of, 
Phlegmonous  inflammation  of  the  gums, 
Phosphornecrosis,  ........ 

Phosphorus,  effects  of  the  fumes  of,  ujwn  the  teeth  and  adjacent 
tures,         ..... 

Pigment  deposits  in  atrophic  pulps, 
carious  enamel, 
the  hypertrophic  r 
Pivoted  teeth,  caries  of,  . 
Polypi  of  the  mucous  membrane  of  the 
pulp, 

root-membrane. 
Posterior  dental  groove. 
Primary  atrophy,    .... 

Progressive  dentinal  new-formation, 
new-formations,  . 
proliferation  of  cement. 
Proliferation,  sarcomatous,  in  the  pulp, 

of  the  dental  sac, 


oot-membrane, 


antrum, 


205, 
struc- 


PAGE 

205 
347 


464 


ALPHABETICAL    INDEX. 


Prosopalgia,  see  Facial  Neuralgia. 

Protococcus  dentalis,       ........ 

Pterygoid  muscles,  senile  wasting  of  the,        .... 

Ptosis  consequent  upon  dental  caries,     ..... 

Ptyaline,  .......... 

Puccinia  graminis, ......... 

Pulp,  dental, 

abscesses  in  the,    ........ 

adhesion  of  the,  to  the  dentine,    ..... 

atrophy  of  the,     ........ 

resulting  from  inflammation, 

basis  tissue  of  the,         ....... 

bloodvessels  of  the,       ....... 

calcifications  of  the,     ....... 

resulting  from  inflammation, 

colloid  deposits  in  the,  ...... 

combination  of  difi'erent  atrophic  processes  in  the, 

cretefaction  of  the, 

degeneration  of  the,  into  a  soft,  greasy  mass, 

parenchyma  of  the  embryonic,  . 

fatty  degeneration  of  the,    ...... 

resulting  from  inflammation, 

gangrene,  moist  and  dry,  of  the,  .... 

inflammation  of  the,  see  Inflammations. 

in  transverse  and  oblique  fractures,  exposure  of  the,  . 

junction  of  the,  with  the  dentine, 

nerves  of  the,        .... 

net-like  atrophy  of  the, 

new-formations  of  the, 

of  the  milk  teeth,  fattj'  degeneration  of  the, 

pigment  deposits  in  atrophic, 

polypus  of  the,     .... 

sarcoma  of  the,     .... 

sarcomatous  proliferation  of  the, 

sclerosis  of  the,     .... 

cavity  and  dental  canal,  diminution  in  the 
Purulent  infiltration  of  the  alveolar  process, 

jaws,  . 
Pyorrhoea  alveolaris,       ..... 


size  of,  in  old  age 


Kedness  of  the  pulp  in  inflammation,     ..... 
Eeddish  color  of  the  dentine  with  inflammation  of  the  pulp, 

teeth,  occurs  as  an  anomaly  of  formation, 
Keflex  phenomena  in  connection  with  neuralgias, 

the  first  dentition,         .... 

the  second  dentition,    .... 


372,  415 

.  269 

437,  440 

354,  365 

.  415 

.  54 

7,  179,  186 

.  241 


191, 


.  178 
183,  370 
.  186 
.  431 
.  434 
.  435 


Keinserted  human  teeth,  caries  of, 


404,  406,  414 


ALPHABETICAL    INDEX. 


465 


Keplantation  of  teeth,     ..... 

Eesection  of  nerves  for  the  relief  of  neuroses, 
Resorption  of  bone  in  the  jtiws,  interstitial,  . 

hypertrophic  cement,  interstitial, 
perforating, 
peripheral, 
senile  dentine  and  cement, 

the  angle  of  the  lower  jaw,  peripheral  and  pericellular 
the  alveolar  process,  senile,     ..... 

the  alveoli,  after  extraction  of  the  teeth, 

consequent  upon  inflammation  of  the  root- 
membrane,  ...... 

previous  to  the  eruption  of  the  teeth,  partial, 
the  hard  tissues  of  the  root,  consequent  upon  inflamma- 
tion of  the  root-membrane,  . 
process  in  shedding  the  teeth, 
Retention  of  teeth  without  displacement. 
Rheumatic  aflfection  of  the  root-membrane,  . 

periostitis  of  the  jaws. 
Ridge,  the  dental,   ...... 

Root-membrane,     ...... 

abscesses  of  the,   . 

affections  of  the,  consequent  upon  the  replantation 

and  transplantation  of  teeth, 
affections  of  the,  consequent  upon  the 

substances, 
atrophy  of  the,     . 
bloodvessels  of  the, 
calcification  of  the, 
cancer  of  the, 
cytoblastions  in  the, 
gangrene  of  the,  . 
hypertrophy  of  the, 
inflammation  of  the,  see  Inflammation 
myeloplaxes  in  the, 
nerves  of  the, 
new-formations  of  the, 

symptoms  of  the, 
ossiflcation  of  the, 

pigment  deposits  in  the  hypertrophic, 
polypi  of  the,        .... 

rheumatic  affection  of  the,  . 
senile,   ...... 

tumors  of  the,       .... 

Root,  periosteum  of  the,  see  Root-Membrane. 
Roots,  abscesses  of  the,  causing  affections  of  the  ciliary  nerves, 

30 


PAGE 
216 

480 
92 
274 
274 
273 
245 
269 
266 
259 

213 
71 

212 

77 

127 

216 

224 

61 

58 

210 

.  215 
use  of  various 

.  214,  215 

.  255 

.   59 

.  255 

.  317 

317 

211 

277 


59, 


59,  317 

.  60 

.  316 

.  317 

.  256 

.  279 

.  318 

.  216 

.  255 

.  316 

.  438 


46G 


ALPHABETICAL    INDEX. 


PAGE 

Eoots  and  crowns,  dwarfish, 157 

flexions  and  torsions  of  the,      .....     130 

condyloid  or  nodular  enlargements  at  the  extremities  of  the,  138,  139 
diminished  number  of,  ........     140 

extension  of  caries  to  the,    ........     392 

facial  neuralgia,  consequent  upon  the  concrescence  of,        .         .     435 
flexions  of  the,      ..........     132 

formation  of  the,  when  completed,      ......       70 

general  monstrous  malformation  of  the  crown  with  well-formed,     158 
general  malformation  of  the  crown  of  a  molar  with  undeveloped 
growth  of  the,       ....... 

of  permanent  teeth,  caries  of  the, 
supernumerary,    ....... 

union  of  the,         ....... 

unusually  long  or  thick,  divergent  and  curved,  . 


Saliva,  acidity  of  the,     . 
alkalinity  of  the, 
appearance  and  properties  of  the, 
the  mixed,  .... 

nitrous  acid  salt  in, 
sugar  in,    . 
sulphocyanic  acid  in 
urea  in, 
Salivarj'  calculus,   .... 
fistula,      .... 
glands,      .... 
secretion  of  the,  . 
Sarcomata  of  the  sums, 


jaws, 
pulp. 


Sarcomatous  proliferations  in  the  pulp, 

of  the  dental  sac, 

Sclerosis  of  the  pulp, 

Scorbutic  gums,       .... 

Scrofulous  teeth  [Note),  . 

Second  dentition,    .... 

changes  in  the  jaws  during  the, 
convulsions  caused  by  anomalies  in  the, 
diseases  caused  by  the, 
epilepsy  caused  by  anomalies  in  the,  . 
mental  aberration  caused  bj'  anomalies  in 
neuralgias  caused  by  anomalies  in  the. 

Secondary  atrophy,         ....... 

dentine,  ....... 

osteoids,  ....... 


140, 14 


the. 


219 


158 
70 
396 
136 
152 
138 


355 
356 
354 
355 
355 
356 
355 
356 
365 
221 
354 
354 
320 
343 
286 
191 
346 
240 
255 
142 
76 
91 
435 
201 
435 
435 
435 
232 
289 
347 


ALPHABETICAL    INDEX. 


467 


the 


temp 


les  o 


Secretion  of  the  gums,    .... 
mucous  glands,     . 

membrane, 
salivary  glands,    . 

Senile  alveolus, 

atrophy,        ..... 

of  the  gums,   . 
cement,  ..... 

calcification  of  the  root-membrane, 
changes  in  the  angle  of  the  lower  jaw 
dentine,         ..... 
enamel,         ..... 

membrane, 
flattening  of  the  articular  eminence  of 
ossification  of  the  root-membrane, 
resorption  of  the  alveolar  process, 
cement, 
dentine,     . 
root-membrane,    .... 
wasting  of  the  coronoid  processes  and  condy 

masseter  and  pterygoid  muscles, 
maxilla, 
Sensations  produced  in  the  teeth  by  certain  sound; 
Sensitiveness  of  the  dentine,  .... 
Shedding  the  teeth,  process  of,        .         .         . 
Socket,  atrophy  of  the,  ..... 
cicatrization  of  the,  .... 
Specific  gravity  of  the  teeth, 

periostitis  of  the  jaws. 
Spirillum,        ....... 

Stomatitis, 

hemorrhagica,       .... 
ulcero-membranacea,    . 
Structure  of  the  teeth,  irregularities  in  the,  . 

Supernumerary  roots, 

teeth,     ..... 

Surfaces  upon  the  crown,  produced  by  friction, 
Sutura  incisiva,       ...... 

Syphilis,  changes  in  the  form  of  teeth  indicative 
inflammation  of  the  gums  in, . 


f  the 


Tartar, 

Teeth,  see  Temporary  and  Permanent  Teeth, 
anesthesia  of  the,         .         .         .         , 
artificial  caries  of  the, 
blending  or  fusion  of  adjacent,  . 


f, 


oral 


bone, 


lower 


jaw, 


100, 


37 


.     443 
I,  375,  407 
.     147 


468 


ALPHABETICAL    INDEX. 


PAGE 

374,  376,  406,  414 

404,  406,  414 

.     357 


Teeth,  caries  of  artificial, 

reinserted  human  teeth, 

the, 

different  kinds  of,  . 
changes  in  the  form  of,  indicative  of  syphilis, 
classification  of  the,     ..... 

cleavage  of  the,  ...... 

coalescence  or  concrescence  of  adjacent,     . 

coating  upon  the, 

formation  of  the,    . 
living  organisms  in  the, 
conical,        ....... 

deficiency  of,        .....         . 

density  of, 

development  of  the,    ..... 

distinctions  between  temporary  and  permanent 
effects  upon  the  hearing  caused  by  diseased, 
elasticity  of  the, ...... 

extraction  of,  a  special  cause  of  neuralgias, 
fractured,    ....... 

cases  of,       ....         . 

conditions  necessary  for  the  union  of, 
general  characters  of  the,   . 
hard  tissues  of  the,      .... 

in  a  case  of  congenital  hydrocephalus, 
in  ovarian  cysts,  .... 

irregularities  in  the,  see  Irregularities. 

Magitot's  experiments  with  various  substances  upon  the, 

malformations  of  the,  see  Malformations. 

neuralgias  consequent  upon  impacted, 

neuroses  consequent  upon  affections  of  the,  abstract  of  cases  of, 

new-formations  of  the,  see  New-formations. 

of  animals,  caries  of  the,    . 

malformations  of  the, 
new-formations  of  the, 
wear  of  the,     . 
of  elephants,  musket-balls  in  the, 
peculiarities  of  the  tissues  in  grooved,         .... 

relation  between  affections  of  the  uterus  and  those  of  the  {Note) 
pivoted,  caries  of,         .         .         . 


29, 


393 

146 

30 

.  376 

.  147 

.  357 

.  361 

.  357 

100,  102 

104,  107 

28 

60 

40 

441 

30 

432 

307 

307 

309 

28 

43 

148 

172 


reinserted  human,  caries  of, 
replantation  of,   . 

retention  of,  without  displacement, 
shedding  the,       .         .         .         • 

resorption  in  connection  with, 
specific  gravity  of,       .........       28 


407 

435 
435 

410 

167 

297 

253 

301 

44 

432 

.     406 

374,  376,  406,  414 

.     216 

.     127 

.  ■       .         .77 

77 


ALPHABETICAL    INDEX. 


469 


facial 


Teeth,  supernumerary,  ........ 

transplantation  of, 

trephining  the,  Dobbelin's  operation   for  the  relief  of 
neuralgia,       ........ 

Teething,  see  Dentition. 

inflammation  of  the  gums  attending,     . 
rare  sequelae  of  inflammation  of  the  gums  attending, 
Temporary  and  permanent  dental  arches,  comparison  of  the  eh 
in  the,      ..... 

Temporary  teeth,  arrangement  of  the, 
blending  of  the, 
caries  of  the, 
deficiency  of  the, 
description  of  the, 
distinction  between  permanent  and, 
eruption  of  the, 
excessive  number  of  the,    . 
fatty  degeneration  of  the  pulps  of, 
intervals  between  the  eruption  of  th 
irregularities  in  the  position  of  the, 
size  of  the. 
Tetanus  following  the  extraction  of  a  tooth. 
Theories  of  caries,  .... 

Third  dentition,      .... 

Thrush, 

Tomes'  processes  of  the  dentinal  cells. 
Torsions  and  flexions  of  the  crowns  and  root 

axial,  of  the  crowns, 
Transplantation  of  the  teeth, 
Transverse  fractures  of  the  crowns,  exposure  of  the  pulp  in 

root,     . 
Traumatic  periostitis  of  the  jaws,  . 
Trephining  the  teeth  for  the  relief  of  neuralgias, 
Trifacial  nerve,  afi"ections  of  the  ciliary  nerves  and  apparatus  of  vision 

from  irritation  of  the,      .... 
Trismus  cured  by  the  extraction  of  a  first  molar, 
Tumors  of  the  root-membrane, 

symptoms  of  the. 
Tusks  of  elephants,  abscess  in  the. 
Twin-malformations,       ..... 

distinguished  from  blended  teeth. 


P.^GE 

100,  L35 
216 


434 

199 
201 

95 

43 

149 

396 

107 

38 

40 

73 

102 

233 

75 

121 

99 

436 

411 

87 

194 

64,  68 

130 

132 

216 

311 

309 

224 

434 


438 

436 

316 

317 

188,  304 

140,  170 

.     149 


Ulceration  of  the  gums  consequent  upon  catarrhal  inflammation,         .  194 

Undermining  caries  of  the  dentine, 389 

enamel,  ......  382 

Underhung, HO 


470 


ALPHABETICAL    INDEX. 


Union  of  roots, 140,  147,  152 

Upper  jaw,  see  Jaw. 

cystoid-gelatinous  cancer  of  the, 351 

description  of  the, 22 

ossification  of  the,        ........  88 

periostitis  of  the,  see  Periostitis. 

Uterus,  relation  between  afiectious  of  the  teeth  and  those  of  the  {Note)^  432 

Upright  teeth, 110 


Vascular  tumors  of  the  gums, 

Vaso-dentine, 

Yestibulum  oris,     ...... 

Volume  of  the  pulp,  increased  in  inflammation, 


.     320 

46,  188 

.     218 

.     178 


Wearing  away  of  the  teeth  by  attrition,  forms  in  which  and  means  by 

which  it  is  effected  [Note),        .         .         .         .         .         .         .         .  247 

Wedge-shaped  defects  upon  the  facial  surface  of  the  dental  neck,         .  253 

White  caries, 408 

Wisdom  teeth,  development  of  the,       .......  86 

duplication  of  the, 140 

eruption  of  the,     ........  86 

Wolf's  jaw, 89 


THE     END. 


CATALOGUE 

OF  THE 

FTJBLIOATIONS 

OF 

Lindsay  &  Blakiston, 

INCLUDING  WORKS  ON 


The  Practice  of  Medicine, 
Surgery, 
Anatomy, 
Physiology, 
Materia  Medica, 
Ophthalmoscopy, 
Therapeutics, 


Diseases  of  Women, 
Diseases  of  Children, 
Obstetrics, 
Pathology, 
Chemistry, 
Pharmacy, 
Dentistry, 


AND 

THE  COLLATERAL  SCIENCES. 

ALSO, 

PHYSIOLOGICAL,  ANATOMICAL,  AND 

,  OBSTETRICAL  MAPS  AND  DIAGRAMS, 


THE  SYDENHAM  SOCIETY'S  PUBLICATIONS, 

PHYSICIANS'  VISITING  LISTS, 

&c.,   &c. 


Any  of  the  boots  in  this  Catalogue  can  be  bad  at  tbe  prices  annexed, 
from  or  tbrougb  tbe  principal  Booksellers  in  tbe  United  States 
and  Canada ;  or  tbey  will  be  sent  free  by  mail  to  persons  wbo 
cannot  obtain  them  otherwise,  upon  tbe  receipt  of  the  amount  by 
the  Publishers,  ^j^^g^Y  &  BLAKISTON. 


Philadelphia, 
September  1872. 


No.  25  South  Sixth  Street, 

PHILADELPHIA. 


NEW  BOOKS  AND  NEW  EDITIONS, 
Published  by  LINDSAY  &.  BLAKISTON,  Philadelphia. 

NOW    RILVDY. 
JLitkin's  Science  and  Practice  of  Medicine,      Tliird  American,  from   th 

Sixth  London  Edition.     Thorouglily  Revised,  Remodelled,  and  partially  rewrittei 

with  many  New  Illustrations.     2  vols..  Royal  Octavo. 
HetviWs  Diagnosis,  Patlioloqy ,  ainl  Treatment  of  the  Diseases  o 

IFomen,.     Tlie  Third  Enlarged  Edition. 
Blade's  Functional  Diseases  of  the  Urinary,  Renal,  and  Reproduc 

five  Oi'f/ans. 
Hurley.     The  Urine  and  its  Deranf/emenfs.     With  Illustrations. 
HcH'son,.     Earth  as  a  To/)ical  Application  in  Surgery.     Illustrated. 
Physicians'  J'isiting  List  for  1S7S.     Various  sizes,  styles,  and  prices. 
Wedl.     The  Pathology  of  the  Teeth.     Illustrated. 
Lewin  on  the  Treatment  of  Sypltilis.     With  Illustrations. 
Peasley's  Book  of  3000  Prescriptions.     The  Fourth  Revised  Edition. 
Beale.     Disease  Germs.     Second  Edition,  much  enlarged,  with  a  New  Part  o 

the  Distribution  of  Disease  Germs,  and  28  Phites,  many  of  them  colored. 
Bindfleisch's  Text-hook  of  Pathological  Histology,     Illustrated. 
Meadows'  Netv  Text-hook  of  Obstetrics.     Second  Edition.     Illustrated. 
Tanner's  3Iannal  of  Poisons.     A  New  Enlarged  Edition. 
Boss,     The  Graft  Theory  of  Disease. 

Bloxam's  Chemistry,  Inorganic  and  Organic.    Second  Edition. 
Cooley,     Cyclopedia  of  Beceipts.     Fifth  London  Edition,  much  enlarged. 
Take.    Blustrations  of  the  Tnflaence  of  the  Mind  on  the  Body. 
Dobell.      Winter  Cough.     New  Edition.     Colored  Illustrations. 
Arnott  on  Cancer.     With  Illustrations. 
Elain.     On  Cerebra  and  other  Diseases  of  the  Brain. 
Ward.     On  some  Affections  of  the  Liver  and  Intestinal  Canal. 
Legg,     The  Examination  of  the  Urine.     Third  Edition. 
Mackenzie.     On  Laryngeal  Growths.     Colored  Illustrations. 

*'  Pharmacopoiia  of  the  Hospital  for  Diseases  of  the  Throat 

Beynold's  Clinical  Uses  of  Electricity. 
Bigby's  Obstetric  3Iemoranda.     Fourth  Edition. 
Gant's  Irritable  Bladder.     Third  Edition. 
Habershon  on  Diseases  of  the  Liver. 

NEARLY    RKADY. 
Atthill's  Clinical  Lectures  on  the  Diseases  of  Women.     Second  Editior 

Enlarged  and  Illustrated. 
Fothergill  on  Disettses  of  the  Heart,  and  their  Treatment. 
Trousseau's  Clinical  Lectures.     Vol.  5,  completing  the  worlc. 
3Iacnamara  on  Diseases  of  the  Eye.    Second  Edition. 

IN    PREPARATION. 
Sanderson  and  Foster's  Hand-book  for  the  Laboratory, 
Stvevingen's  Pharmaceutical  Lexicon, 
Coles.    Dental  3Iechanics.     Illustrated. 

Brunton.     Experimental  Investigation  into  the  Action  of  3Iedicine€ 
Gant.     The  Science  and  Practice  of  Surgery.     Second  Edition. 
Allingham  on  tJte  Rectum,  tCv.     Second  Edition. 
Fuller  on  Rheu mutism ,  Sc.     A  New  Edition. 
Fuller  on  the  Heart,  Lungs,  tDc.     Second  Edition. 
Tomes'  Dental  Surgery.     A  New  Enlarged  Edition. 
Walton,  on  the  Eye.     From  the  Tliird  London  Edition. 
Hardwick's  Photogruphic  Chemistry.     Eighth  Edition. 
Martin's  3Iicroscopic  3Iounting. 

S^"  For  particulars,  see  under  alphabetical  arrangement,  in  Catalogue. 


LINDSAY   AND    BLAKISTON  S    PUBLICATIONS. 


"  The  Representative  Book  of  Medical  Science."  —  London  Lancet. 

Aitken's  Science  and  Practice  of  Medicine. 

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rnOROUGHLY    REVISED,    REMODELLED,     MANY     PORTIONS     REWRITTEN,     AVITH 
ADDITIONS     EQUAL     ALMOST     TO    A    THIRD    VOLUME,    AND     NU- 
MEROUS   ADDITIONAL    ILLUSTRATIONS,    WITHOUT 
ANY  INCREASE  IN   BULK  OR  PRICE, 

The  Science  and  Practice  of  Medicine.  By  William  Aitken,  M.D.,  Fro- 
fcHsor  of  Pathology  in  the  Army  Medical  School,  &c.,  &c.  The  Thir^d 
American,  from  the  Sixth  London  Edition,  edited  with  Additions  De 
!<criptive  of  Certain  Forms  and  Types  of  Disease  peculiar  to  this 
Country,  and  their  Modes  of  Treatment,  by  Meredith  Clymer,  M.D  , 
ex-Frofessor  of  the  Institutes  and  Practice  of  Medicine  in  the  University 
of  New  York,  now  Professor  of  the  Diseases  of  the  Nervous  System  and 
of  the  Mind  in  the  Albany  3Iedical  College,  &c.  In  Two  Yolunies 
Eoyal  Octavo.  With  a  Colored  3Iap,  a  Lithogi-aphic  Plate,  and  nearly 
Two  Hundred  Illustrations  on  Wood. 

Price,  bound  in  Cloth,  bevelled  boards,    ....         $12.00 
"  "  Leather, 14.00 

For  eigliteen  roonths  Dr.  Aitken  has  been  engaged  in  again  carefully  revising  this  Great  Work,  and  adding 
to  it  many  valuable  additions  and  improvements,  amounting  iu  the  aggregate  almost  to  a  volume  of  new 
matter,  included  in  which  will  be  found  the  adoption  and  incorporation  in  the  text  of  the  "nefw  nomenclature 
vf  the  Royal  College  of  Physicians  of  London  ;  "  to  which  are  added  the  Definitions  and  tlie  Foreign  equivalents 
for  their  English  names ;  the  New  Classification  of  Disease  as  adopted  by  the  Royal  College  of  Physicians,  &c. 

Dr.  Aitken's  Practice  is,  by  almost  universal  consent,  both  in  England  and  the  United  States,  acknowl- 
edged to  be  in  advance  of  all  other  works  on  "TJie  Science  and  Practice  of  Medicine."  It  is  a  most  tuorougli 
ianil  complete  Test-book  for  students  of  medicine,  following  such  a  systematic  arrangement  as  will  give  tliem 
la  consistent  view  of  the  main  facts,  doctrines,  9,nd  practice  of  medicine,  in  accordance  with  accurate  physio- 
llogical  and  pathological  principles  and  the  present  state  of  science.  For  the  practitioner  it  will  be  found 
equally  acceptable  as  a  work  of  reference. 

The  author's  plan  has  been  carried  out  to  that  perfection  that  the  treatise  is  as  complete  a  one  as  can  be 
found  in  any  language.  Evei-y  department  of  medicine,  whether  relating  to  pathology,  nosology,  diagnosis, 
ll|,or  treatment,  is  most  elaborately  and  thoroughly  discussed.  The  editor,  Dr.  Meredith  Clymer,  has  contrib- 
uted liis  share  to  the  work  by  many  judicious  additions  to  the  original  text,  which  makes  the  work  particu- 
larly valuable  to  the  American  practitioner.  As  a  whole,  it  now  forms  a  complete  cyclopiedia  of  medicine, 
und  commends  itself  to  those  practitioners  and  students  who  have  a  desire  to  perfect  their  knowledge  of  our 
irt,  and  gain  much  of  that  information  which  is  crowded  out  of  the  smaller  text-books. 

N.  T.  Medical  Record. 
It  must  now  be  looked  upon  as  the  standard  text-book  in  the  English  language. 

Edinburgh  Medical  Journal. 
All  the  light  which  recent  advances  have  made  in  the  method  of  examining,  diagnosing,  and  treating  of 
liseases  are  here  imparted.  British  and  Foreign  Medico- Cldrurgicul  Review. 

It  forms  the  latest  and  most  scientific  work  on  medicine  yet  published.        London  Medical  Times  and  Gazette, 
id  i  It  is  the  most  com])rehen8ive  work  that  has  ever  been  published  on  the  Practice  of  Medicine. 

British  Medical  Journal. 
By  the  student  it  will  bo  found  to  be  the  most  useful  and  comprehensive  text-book  extant. 

Glasgow  Medical  Journal. 
The  great  merit  of  this  work  of  Dr.  Aitken's  is,  that  it  treats  the  various  forms  of  disease  according  to 
scientific  classification.  Alhenseum. 

Dr.  Aitken's  work  at  once  took  the  first  place  among  text-books,  and  will  hold  that  position  for  years  to 
ome.  Medical  Mirror. 

Dr.  Aitken's  work  is  an  admirable  one  for  the  student  and  busy  practitioner.    A  more  excellent  one  we 
ally  do  not  know.  London  Lancet,  May  13, 1865. 

Ill  Or.  Aitken's  book,  diseases  are  described  which  have  hitjierto  found  no  place  in  any  English  system- 
i  ■  work.  Wettminster  Revieui. 


New  Book  on  Diseases  of  Women. 

SECOND  EDITION,  REVISED  AND  ENLARGED. 

Attliill's  Clinical  Lectures  on  Diseases  Pecul- 
iar to  Women.  By  Lombe  Atthill,  M.D.,  Felloio  and 
Examiner  in  Midwifery,  King  and  Queen^s  College,  of  Physicians , 
Ohsletric  Physician  to  the  Adelaide  Hospital,  and  formerly  A^sintan 
Physician  to  the  Rotundo  Lying-in  Hospital.  Demy  Octavo,  with 
Illustrations,      Nearly  Ready. 

"  This  excellent  little  book  has  three  great  merits.  It  treats  of  very  common  disease; 
which  are  generally  very  badly  taught  in  our  Schools.  Secondly,  it  treats  of  them  in 
a  thoroughly  clinical  and  practical  way  ;  and  finally,  witliout  being  too  short,  is  s 
compact  book,  calculated  to  be  very  useful  to  the  practitioner.  Dr.  Atthill's  practice 
if  not  original,  is  thoroughly  independent,  and  he  illustrates  it  with  a  copious  quota 
tioii  of  good  cases.  We  commend  the  vvliole  book  to  the  careful  attention  of  advanced 
students  and  general  practitioners."  — Lancet, 31arck  23,  1872. 

"  The  lectures  before  us  have  the  merit  of  calling  attention  to  this  important  subjee 
with  the  voice  of  personal  experience.  Those  on  Menorrhagia,  endo- Metritis,  anc 
endo-Cervicitis,  we  would  specially  point  out  as  worthy  of  note;  and,  without  endors 
ing  the  author's  therapeutic  treatment  of  those  affections,  we  cannot  but  admire  th 
clearness  of  style  and  practical  character  of  their  literary  treatment."  —  Glasgoi 
Medical  Journal,  May,  1872. 

"  These  lectures  form  an  admirable  text-book  for  students.  Dr.  Atthill,  as  Examine 
in  the  Queen's  University  and  College  of  Physicians  of  Ireland,  discovered  the  utte 
ignorance  of  the  majority  of  students  on  the  important  subject  of  Diseases  Peculiar  t 
Women.  The  publication  of  this  little  volume  supplies  a  want  that  has  long  been  fel 
by  students  preparing  for  examination.  In  these  lectures  is  to  be  found  a  clear  an' 
concise  summary  of  the  clinical  practice  of  the  diseases  peculiar  to  women.  The  wor 
is  the  result  of  large  and  accurate  clinical  observation,  recorded  in  an  admirably  terse  an 
perspicuous  style,  and  is  remarkable  for  the  best  qualities  of  a  practical  guide  to  th 
student  and  practitioner."  —  British  Medical  Journal,  May  11,  1872. 

"  A  most  excellent  though  brief  hand-book  on  the  Diseases  Peculiar  to  Women  ;  on 
that  cannot  fail  to  be  of  great  use  to  students,  and  that  will  guide  them  to  a  rigl 
understanding  of  the  cases  brought  before  them  in  their  hospital  practice.  Nor 
this  all;  to  the  busy  practitioner  this  book  will  be  of  use  in  many  an  emergency,  n< 
only  assisting  him  in  the  recognition  of  the  various  forms  of  disease  most  frequentl 
met  with,  but  also  forming  a  safe  and  reliable  guide  to  their  treatment  on  sound  an 
scientific  principles.  We  think  Dr.  Atthill  has  done  good  service  in  publishing  h 
lectures,  and  we  strongly  recommend  them  to  the  careful  and  attentive  perusal  of  a 
who  wish  to  study  the  diseases  of  women." — Dublin  Journal  of  Medical  Science,  Noven 
ber,  1871. 

"A  very  useful  and  judiciously  written  work." — British  and  Foreign  Medico-Chiru 
(jical  Review,  April,  1872. 

"Da\  Atthill  has  done  good  service  by  giving  to  the  world  a  concise,  lucid,  and  ine: 
pensive  treatise  on  the  more  commonly  met  with  forms  of  Uterine  disease.  We  cann 
conclude  without  expressing  our  surprise  and  gratification  that  so  much  valuab 
information  has  been  condensed  into  so  small  a  compass." —  The  Medical  Press  and  Q 
culor,  November  15,  1871. 

"  The  author  has  compressed  into  a  small  work  a  large  amount  of  information  of  tl 
most  useful  kind.  The  lectures  are  strictly  clinical,  and  the  conciseness  with  whi 
Dr.  Atthill  discusses  his  subjects  will  make  the  work  a  favorite  with  general  prac 
tioners,  and  this  it  deserves  to  be." —  The  Doctor,  Ajrril  1,  1872. 

JLrnOtl   on    OanCer.  itsVarieties,th.eir  Histology  and  Diagnost 
By  Henry  Arnott,  F.R.C.S.,  Assistant  Burgeon  to  St.  Thomas'  Ho 
pital.     Illustrated  by  Five  Lithographic  plates  and  Twenty-two  Wo 
Engravings,  drawn  from  Nature.     Octavo.     Price,    .         .         $2 1 


lilNDSAY    AND    BLAKISTON  S    PUBLICATIONS. 

Alliiigham  on  Fistula,  Hemorrhoids^  Painful 

Ulcer,  Stricture,  Prolapsus,  and  other  Diseases  of 
the  Rectum,  their  Diagnosis  and  Treatment.  By  AVilliam  Alling- 
HAM,  Fellow  of  the  Royal  College  of  Surgeons  of  England,  Surgeon 
to  St.  Mark^s  Hospital  for  Fistula,  &c.     New  Edition  preparing. 

The  Medical  Press  and  Ctrctiter,  speaking;  of  this  book,  says:  "No  book  on  this  special  subject  tliat  cuii  at 
all  approach  Mr.  AUingham's  in  precision,  clearness,  and  practical  good  sense  '" 

,\ud  r/ie /."nJoit  Xancf(;  —  "  Asa  liractical  guide  to  the  tre.umeiit  uf  alTcclions  of  the  lower  bowel,  t!ii=- 
book  is  wurtliy  of  all  commendation." 

Adams  on  Club-Foot. 

Its  Causes,  Pathology,  and  Treatment.  Being  the  Jacksonian  Prize 
Essay  for  1864.  By  William  Adams,  F.R.C.S.,  Surgeon  to  the  Royal 
Orthopsedic  and  Great  Northern  Hospitals.  A  New  Edition,  with 
Numerous  Illustrations.     In  preparation. 

Adams  on  Rheumatic  and  Strumous  Diseases 

Op  the  Joints  ;  including  Hip-Joint  Disease,  and  the  Treatment  for 
the  Restoration  of  Motion  in  Cases  of  Stif -Joint  or  Partial  Anchylo- 
sis. The  Lettsomian  Lectures  delivered  before  the  Medical  Society 
of  London  in  lS{]d.     In  preparation. 

Acton  on  the  Functions  and  Disorders  of  the 
Reproductive  Organs,     new  edition. 

In  Childhood,  Youth,  Adult  Age,  and  Advanced  Life,  considered  in  their 
Physiological,  Social,  and  Moral  Relations.  By  William  Acton,  M.R. 
C.  S.,  etc.  Third  American  from  the  Fifth  London  Edition.  Care- 
fully revised  by  the  author,  with  additions.    Just  Ready,  octavo,  $3.00 

To  such  of  our  readers  as  are  not  familiar  with  Acton's  book,  we  may  say  that  his  plan  embraces  the  con- 
llkJeration  of  topics  of  great  interest :  such  as  are  peculiar  to  childhood,  embracing  Its  vices ;  those  peculiar 
to  precocity  and  included  in  masturbation;  similar  inquiries  pertaining  to  youth  and  adult  age,  and  so  on 
through  the  stages  of  life  with  its  Inquiries.  Indeed,  we  may  say  that  all  those  delicate  matters  pertaining 
to  the  male  sexual  conditions  are  treated  in  this  volume  with  singular  care  and  intelligence.  —  Lancet  and 
Obsercer,  October,  1871. 

Anstie  on  Stimulants  and  Narcotics. 

Their  Mutual  Relations,  with  Special  Researches  on  the  Action  of  Alcohol, 
Ether,  and  Chloroform  on  the  Vital  Organism.  By  Francis  E.  Anstie, 
INI.D.,  Assistant  Physician  to  Westminster  Hospital,  Lecturer  on  Materia 
Medica  and  Therapeutics,  etc.,  etc.     Octavo,   .         .         .         .         $3.00 

Aithaus'  Medical  Electricity,    a  New  and  very  much 

Enlarged  Edition. 
A  Theoretical  and  Practical  Treatise,  and  its  Use  in  the  Treatment  of 
Paralysis,  Neuralgia,  and  other  Diseases.  By  Julius  Althaus, 
M.  D.,  Memlter  of  the  Ruyal  College  of  Physicians,  &c.  Second 
Edition,  revised,  enlarged,  and  for  the  most  j^art  rewritten.  In  One 
Volume  Octavo.  v.nth  a  Lithographic  Plate  and  sixty-two  Illustrations 
an  Wood      J'r.ce.  ...  .  .  .  $5.00 


LINDSAY   AND    BLAKISTON's   PUBLICATIONS. 


Byford's  Practice  of  Medicine  and  Surgery. 

Ap])lied  to  the  Diaeases  and  Accidents  Incident  to  Wovien.     By  W.  H. 
.Byf()HD,  A.m.,  M.D.,  Professor  of  Obstetrics  and  Diseases  of  Women 
and  Children  in  the  Chicago  Medical  College,  &c.,  &c.     Second  Edi- 
tion, Revised  and  Enlarged.     Octavo.  ....         $5.00 
Tliis  work  treats  well-nigh  all  the  diseases  incident  to  women,  diseases  and  accidents 
of  the  vulva  and  perineum,  stone  in  the  bladder,  inflammation  of  the  vagina,  menstru- 
ation and  its  disorders,  the  uterus  and  its  ailments,  ovarian  tumors,  diseases  of  the 
mammie,  puerperal  convulsions,   phlegmasia  alba  dolens,  puerperal  fever,   &c.     Its 
scope  is  thus  of  the  most  extended  character,  yet  the  observations  are  concise,  but 
convey  much  practical  information.  —  London  Lancet. 

Byford  on  the  Uterus,  second  edition,  now  Ready. 

On  the  Chronic  Inflammation  and  Displacement  of  the  Unimpregnatcd 
Uterus.     A  New,  Enlarged,  and  Thoroughly  Revised  Edition,  with 
Numerous  Illustrations.     Octavo.         .....         $3.00 

Dr.  Byford  writes  the  exact  present  state  of  medical  knowledge  on  the  subjects  pre- 
sented; and  does  this  so  clearly,  so  concisely,  so  truthfully,  and  so  completely,  that 
his  book  on  the  uterus  will  always  meet  the  approval  of  the  profession,  and  be  every- 
where regarded  as  a  popular  standard  work.  —  Buffalo  Medical  and  Surgical  Journal, 
August,  1871. 

Black  on  the  Functional  Diseases  of  the  Renal, 

Urinary,  and  Reproductixe  Organs,  with  a  General  View  of  Urinary 
Pathology.  By  D.  Campbell  Black,  M.D.,  L.R.C.S.  Eclinburyh, 
Member  of  the  General  Council  of  the  University  of  Glasgow,  &c.,  dc 
Octavo.     Price, $2.50 

Bloxam's  Chemistry,  Inorganic  and  Organic. 

With  Exjoeriments  and  a  Comparisoyi  of  Equivalent  and  Molecular  For- 
mulae. With  276  Engravings  on  Wood.  By  C  L.  Bloxam,  Profes- 
sor of  Chemistry  in  King-s  College,  London.  Second  Edition,  care- 
fully revised.     In  preparation.        .....  ^6.50 

Bloxam's  Laboratory  Teaching; 

Or,  Progressive  Exercises  in  Practical  Chemistry.  With  Analytical 
Tables.     Second  Edition,  with  89  Engravings.     .         .         .         $2.25 

Brunton's  Experimental  Investigation  of  the 
Action  of  Medicines. 

A  Hand-book  of  Practical  Pharmacology.  By  T.  Lauder  Brunton, 
M.D.,  D.Sc,  Lecturer  on  Materia  Medica  at  the  Middlesex  Hospital. 
12ino.     With  Wood-cuts.     In  preparation. 

Beeton's  Book  of  Household  Management. 

With  Sanitar-y,  Medical,  and  Legal  Memorandums ;  also,  a  History  of 
the  Properties  and  Uses  of  all  Things  connected  with  Home  Life  and 
Comforts.  12  Colored  and  600  other  Illustrations.  1100  pa<?es. 
Deiuy-octavo.         .........         $3.25 

Bianston's  Hand-Book  of  Practical  Receipts. 

Fur  the  Chemist,  Druggist,  and  Medical  Practitioner,  compinsing  the 
Officinal  Medicines,  their  Uses,  and  Modes  of  Preparation,  and  For- 
mal x  for  Trade  Prejmrations,  &c.;  with  a  Glossary  of  Medical  and 
Chemical  Terms.  ........         $1.5C 


LINDSAY    AND    BLAKISTON'a    PUBLICATIONS. 


Beasley's  3000  Prescriptions. 

FOURTH  REVISED  AND  ENLARGED  EDITION. 

Containing  3000  Prescriptions,  collected  from  the  Practice  of  the  most 
Eminent  P/iysiciajis  and  Surgeons  —  English,  French,  and  American; 
compi'ising  also  a  Compendious  History  of  the  Materia  3Iedica,  Lists  of 
the  Doses  of  all  Officinal  and  Established  Preparations,  and  an  Index 
of  Diseases  and  their  Remedies.  Bj  Henry  Beasley.  Fourth  Edi' 
tion,  Revised  and  Enlarged.     Price,     .....         $2.50 

This  edition  of  Dr.  Beasley's  Book  has  been  carefully  revised  by  the  Author,  and 
many  additions  made  to  it.  The  Publishers  by  printing  it  more  compactly  are  enabled 
to  present  it  in  a  more  convenient  form,  and  sell  it  at  a  much  reduced  price. 

"The  editor, carefully  selecting  from  the  mass  of  materials  at  his  disposal,  has  compiled  a  volume,  in  which 
both  physician  and  druggist,  prescriber  and  compounder,  may  find,  under  the  head  of  each  remedy,  the  man- 
ner in  which  that  remedy  may  be  most  effectively  administered,  or  combined  with  other  medicines  in  the 
treatment  of  various  tliseases.  The  ulphiibetical  arrangement  adopted  renders  this  eaay ;  and  the  value  of  the 
rolnme  is  still  further  enhanced  by  the  short  account  given  of  each  medicine,  and  the  lists  of  doses  of  its 
ieveral  preparations." — Lancet. 

Beasley's  Druggists'  General  Receipt  Book. 

SEVENTH  AMERICAN  EDITION,  REVISED  AND  IMPROVED. 

Comprising  a  copious  Veterinary  Formulary,  numerous  Receipts  of  Patent 
and  Proprietary  Medicines,  Druggists^  Nostrums,  etc. ;  Perfumery  and 
Cosmetics,  Beverages,  Dietetic  Articles  and  Condiments,  Trade  Chemicals, 
Scientific  Processes,  and  an  Appendix  of  Useful  Tables,  by  Henry 
Beasley,  Author  of  the  Book  of  Prescriptions,  etc.,  etc.  Seventh  American 
from  the  Last  London  Edition.     Octavo.        ....         $3.50 

"This  is  one  of  the  class  of  books  that  is  indispensable  to  every  Druggist  and  Pharmaceutist  as  a  book  o( 
reference  for  such  information  as  is  wanted,  not  contained  in  works  used  in  the  regiilar  line  of  his  business, 
Uid  we  can  recommend  it  as  one  of  the  best  of  the  kind."  —  American  DruggiM  Circular. 

Beasley's  Pocket  Formulary. 

THE    NINTH    LONDON    EDITION, 

A  Synopsis  of  the  British  and  Foreign  Pharmacopoeias,  comprising 
Standard  and  Approved  Formulae  for  the  Preparations  and  Com- 
pounds employed  in  Medical  Practice.  Ninth  Edition,  Revised  and 
Enlarged.      Price, •         $2.50 

Bartli  &  Roger's  Manual  of  Auscultation  and 

Jl  erCUSSion.     a  new  American   Translation,  from  the   Sixth 
French  Edition.     16mo $1.25 

Bouchardat's  Annual  Abstract 

Of  Therapeutics,  Materia  Medica,  Pharmacy,  and  Toxicology,  for 
1867.  Translated  and  Edited  by  M.  J.  De  Rosset,  M.D.,  Adjunct  to 
the  Professor  of  Chemistry  in  the  University  of  31aryland.  $1.50 


LINDSAY   AND   BLAKISTON's   PUBLICATIONS. 


WORKS  BY  DR.   LIONEL  S.  BEALE,  F.R.S., 

Follow  of  the  Royal  Cullep;o  of  Physicians,  Physician  to  King's  College  Hospital. 


Seveiifh  Thousand.     Four  Hundred  Illustrations,  some  Colored. 
HOW  TO  WORK  WITH  THE  MICROSCOPE. 

This  work  is  a  complete  manual  of  microscopical  manipulation,  and  contain?  a  full 
description  of  many  new  processes  of  investigation,  with  directions  for  examining 
objects  under  the  highest  powers,  and  for  taking  photographs  of  microscopic  ./bjec:8. 
Octavo.     Cloth.     Price,  $7.50. 

ON   KIDNEY   DISEASES,   URINARY    DEPOSITS,    AND    CALCULOUS 
DISORDERS:—  The  Third  Edition. 
Including  the  Symptoms,  Diagnosis,  and  Treatment  of  Urinary  Diseases.     With  full 
Directions  for  the  Chemical  and  Microscopical  Analysis  of  the  Uvine  in  Health  and 
Disease.     70  Plates,  415  figures,  copied  from  Nature.     Octavo.     Price,  $10.00. 

THE  USE  OF  THE  MICROSCOPE  IN  PRACTICAL  MEDICINE. 

For  Students  and  Practitioners,  witli  full  directions  for  examining  the  various  secre- 
tions, &c..  in  the  Microscope.    4th  Edition.   500  Illustrations.    Octavo.    Price, 

THE  MYSTERY  OF  LIFE. 

An  Essay  in  reply  to  Dr.  Gull's  Theory,  with  two  Colored  Plates.     Price,  $1.50. 

LIFE,  MATTER,  AND  MIND ;  OR  PROTOPLASM. 

With  Original  Observations  on  Minute  Structure,  and  numerous  New  Colored 
Drawings.    A  Neio  Edition,  very  much  enlarged.     Eight  Plates.     Price,  $ 

DISEASE  GERMS :  AND  ON  THE  TREATMENT  OF  DISEASES  CAUSED 
BY  THEM.  Second  Edition,  much  enlarged,  with  28  plates,  [many  of  them 
colored.) 

Part      I.  —  Supposed  Nature  of  Disease  Germs. 
Part    II.  —  Real  Nature  of  Disease  Germs. 
Part  III.  —  The  Destruction  of  Disease  Germs. 

Demy-octavo.     Price,  $5.00 

PHYSICAL  THEORIES    OF  LIFE:   THEIR   INFLUENCE  UPON  RE- 
LIGIOUS THOUGHT.  Price  $2.50. 
With  Observations  on  the  Hypotheses  recently  advocated  by  Tyndall  and  Huxley. 

ON  DISEASES  OF  THE  LIVER,  AND  THEIR  TREATMENT. 

A  Second  Edition,  much  enlarged,  of  the  Author's  AVork  on  the  Anatomy  of  the 
Liver.     Numerous  Plates.     Preparing. 

THE  ARCHIVES  OF  MEDICINE.     Part  XVII.    now  ready.     Price,  $1.50. 

Contents. — Medicine  under  the  Romans — Action  of  Eyelids  in  Expiration;  F. 
C.  Donders,  Utrecht — Lacunae  and  Canaliculi — Nerves  in  Mesenteric  Glands;  Dr. 
Popper,  St.  Petersburg — German  Criticism  and  British  Medical  Science — Homology 
of  Coracoacromial  Ligament;  J.  B.  Perrin — Sulpho-carbolates,  by  Dr.  Sansom — 
Structure  of  the  Liver;  Editor — Sputum  in  Phthisis. 

DISEASE :  ITS  NATURE  AND  TREATMENT.    Preparing. 

New  Researches  on  Inflammation  and  Fever,  and  on  the  Nature  of  Contagion. 
With  Observations  on  the  Cattle  Plague  and  on  Cholera.  Numerous  Colored 
Plates.  Being  the  Third  Course  of  Lectures  delivered  at  Oxford  by  direction  of  the 
RadcliiFe  Trustees. 

All  these  Works  contain  the  results  of  the  Author's  original  investigations.  They  are  Illustrated 
tilh  upuardg  of  2000  Engraoinys,  copied  from  the  actual  objects,  all  of  which  have  been  draun 
rn  tvi'i  d  by  the  Author  himself,  or  under  his  immediate  superintendence. 


LINDSAY    AND    BLAKISTON  S    PUBLICATIONS. 

Bidclle's  Materia  Medica.    foueth  edition. 

For  the  Use  of  Students.     With  Illustrations.     By  J.  B.  Biddle,  M.D 
Professor  of  Materia  Medica  and  Therapeutics  in  the  Jefferson  Med- 
ical College,  Philadelphia,  &c.,  &c.     Revised  and  Enlarged.        $4.00 
This  is  a  thoroughly  revised  and  enlarged  edition  of  Prof.  Biddle's  work  on  Materia 
Medica.     It  is  designed  to  present  the  leading  facts  and  principles  usually  comprised 
under  this  head  as  set  forth  by  the  standard  authorities,  and  to  fill  a  vacuum  which 
seems  to  exist  in  the  want  of  an  elementary  work  on  the  subject.     The  larger  works 
usually  recommended  as  text-books   in   our  Medical  schools  are  too  voluminous  for 
convenient  use.     This  will  be  found  to  contain,  in  a  condensed  form,  all  that  is  most 
valuable,  and  will  supply  students  with  a  reliable  guide  to  the  courses  of  lectures  on 
Materia  Medica  as  delivered  at  the  various  Medical  schools  in  the  United  States. 

Bull  on  the  Maternal  Management  of  Chil- 
dren in  Health  and  Disease. 

Birch  on  Constipated  Bowels. 

The  Various  Causes  and  the  Different  Means  of  Cure.  By  S.  B.  Birch, 
M.D.,  Member  of  the  Royal  College  of  Physicians  of  London,  &c. 
Third  Edition.     Price, $1.00 

Braithwaite's  Epitome  of  the  Retrospect  of 
Practical  Medicine  and  Surgery.  2  vois.  $10.00 

Chambers  on  the  Renewal  of  Life. 

Lectures  chiefly  Clinical,  illustrative  of  a  Restorative  System  of  Medi- 
cine. By  Thos.  K.  Chambers,  M.D.,  Physician  to  St.  Mary's  Hos- 
pital, author  of  "  The  Lidigestions,""  &c.,  &c.  A  new  American  from 
the  Fourth  London  Edition.     Octavo,  .         .         .  $5.00 

"  This  work  is  of  the  highest  merit,  written  in  a  clear,  masterly  style,  and  devoid 
of  technicalities.  It  is  simply  what  it  professes  to  be.  Lectures  Clinical,  delivered 
from  cases  observed  at  the  bedside;  therefore  more  valuable  as  enunciating  the  views 
and  experiences  of  a  practical  mind  aided  by  actual  observation.  They  are  of  deep 
interest,  and  replete  with  facts  having  a  practical  bearing,  and  will  well  repay 
perusal." — Canada  Medical  Journal. 

Chew  on  Medical  Education, 

A  Course  of  Lectures  on  the  Proper  Method  of  Studying  3Iedicine. 
By  Samuel  Chew,  M.D.,  Professor  of  the  Practice  and  Principles 
of  Mediciyie  and  of  Clinical  Medicine  in  the  University  of  Maryland. 

$1.00 
"Dr.  Chew  was  an  eminent  member  of  the  medical  profession,  and  a  well-known 
teacher  cf  medicine.  He  was,  therefore,  well  fitted  for  the  judicious  performance  of 
this  task,  upon  which  he  seems  to  have  entered  with  interest  and  pleasure.  It  is  a 
well-timed  book,  and  will  serve  as  a  most  excellent  manual  for  the  student,  as  well  as 
a  refreshing  and  suggestive  one  to  the  practitioner."  —  Lancet  and  Observer. 


LINDSAY    AND    BLAKISTON'S    PUBLICATIONS. 


Cooley's  Cyclopasdia  of  Practical  Receipts. 

THE  FIFTH  REVISED  AND  ENLARGED  EDITION. 

Containiag  Processes,  and  Collateral  Information  in  the  Arts,  Manu- 
factures, Professions,  and  Trades,  including  Medicine,  Pharmacy,  and 
Domestic  Economy  ;  designed  as  a  Comprehensive  Summary  to  the 
Pharmacopoeias  and  a  General  Book  of  Reference  for  the  Manufac- 
turer, Tradesman,  Amateur,  and  Heads  of  Families.  By  A.  J. 
CooLEY.  Revised  and  partly  Reicritlen  by  Richard  V.  Tusox,  F.C.S., 
&c.  Fifth  and  greatly  Enlarged  Edition.  Over  1000  Royal-octavo 
pages,  double  columns.      With  Illustrations,     Price,  .         .         $12.00 

Cobbold  on  Worms.  Lectures  on  Practical  Helminthology, 
delivered  at  the  Medical  College  of  the  Middlesex  Hosjntal ;  with  Cases 
illustrating  the  Symjjtoms,  Diagnosis,  and  Treatment  of  Internal 
Parasitic  Diseases.     By  T.  Spencer  Cobbold,  M.D.        Price,  $2.00 

With  the  exception  of  hydatid  formations,  the  author  has  in  these  lectures  more  or 
less  fully  considered  all  those  forms  of  internal  parasitism  which  ordinarily  come  under 
the  notice  of  the  physician. 

Coles  on  Deformities  of  the  Mouthj 

Congenital  and  Acquired,  loilh  their  Mechanical  Treatment.  By  James 
Oakley  Coles,  D.D.S.,  Member  of  the  Odontological  Society,  &c.,  <f;c. 
Second  Edition,  Revised  and  Enlarged,  xcith  8  Colored  Engravings 
and  51  Illustrations  on  Wood.       ......         $2.50 

The  second  edition  of  this  work  shows  that  the  author  has  continued  to  devote  him- 
self with  zeal  to  the  investigation  and  treatment  of  a  very  interesting  class  of  cases. 
Mr.  Coles  has  especially  studied  the  congenital  cleft  palate,  and  has,  with  the  mirror, 
detected,  in  several  cases,  growths  in  the  naso-pharyngeal  tonsil.  Very  beautiful 
colored  drawings  are  given  in  illustration  of  the  subject  of  cleft  palate.  Mr.  Coles 
gives  the  preference  to  mechanical  treatment,  in  both  congenital  and  pathological  per- 
forations of  the  palate,  and  his  experience  as  to  the  good  results  obtained  is  certainly 
most  encouraging.  We  recommend  the  work  to  the  studj'  of  both  surgeons  and  den- 
tists. —  Londo7i  Lancet. 

Coles'  Manual  of  Dental  Mechanics. 

With  an  Account  of  the  3Iaterials  and  A]yj)liances  Used  in  Mechanical 
Dentistry,  and  numerous  Engravings  on  Wood.  By  Oakley  Coles, 
Honorari/  Dentist  to  the  Hospital  for  Diseases  of  the  Throat.  In 
preparation. 

Campbell's  Manual  of  Scientific  and  Practical 

Agriculture.     12iuo.      Wtth  illustrations.  .         .         .         81.50 

Clymer's  Epidemic  Cerebro- Spinal  Menin- 
gitis. With  an  Appendix  on  Some  Points  on  the  Causes  of  the  Disease 
as  shown  by  the  History  of  the  Present  Epidemic  in  the  City  of  New 
York.  By  Meredith  Clymer,  M.D.  ( Univ.  Penn.),  Fellow  of  the 
College  of  Physicians  of  Philadelphia,  Professor  of  the  Di-<eases  of 
the  Nervous  S'jstem,  &c.,  &c.  With  a  Map  of  the  City  of  New  York, 
showing  the  Localities,  printed  in  Colors,  of  Cerebro-Spinal  Meningitis 
in  the  Epidemic  of  1872,  made  under  the  Direction  of  Mokeau  Morris, 
M.D.,  City  Sanitary  Inspector  of  the  Health  Department.  Price.    §1.00 


azeaux's  Great  Work  on  Obstetrics. 

THE  MOST  COMPLETE  TEXT-BOOK  NOW  PUBLISHED. 
5REATLY    ENLARGED    AND    IMPROVED. 

CONTAINING   175    ILLUSTRATIONS, 

A  Theoretical  and  Practical  Treatise  on  Midwifery,  including  the  Disease* 
of  Pregnancy  and  Parturition,  by  P.  Cazeaux,  Member  of  the  Impervu 
Academy  of  Medicine ;  Adjunct  Professor  in  the  Faculty  of  Medicine  of 
Paris,  etc.,  etc.  Revised  and  Annotated  by  S.  Tarnier,  Adjunct  Pro- 
fessor in  the  Faculty  of  Medicine  of  Paris ;  Former  Clinical  Chief  of  the 
Lying-in-Hospital,  etc.,  etc.  Fifth  American  from  the  Seventh  French  Edi- 
tion. Translated  by  Wm.  R.  Bullock,  M.  D.  In  one  volume  Royal  Oc- 
tavo, of  over  1100  pages,  with  numerous  Lithographic  and  other  Illustra- 
tions on  Wood. 

Price,  bound  in  Cloth,  bevelled  boards,                      .         ,         .         $6.50 
"  "         Leather,  .  7.50 

kl.  Cazeaux's  Great  Work  on  Obstetrics  has  become  classical  in  its  character,  and 
lost  an  Encyclopaedia  in  its  fulness.  Written  expressly  for  the  use  of  students  of 
dicine,  and  those  of  midwifery  especially,  its  teachings  are  plain  and  explicit,  present- 
;  a  condensed,  summary  of  the  leading  principles  established  by  the  masters  of  the 
tetric  art,  and  such  clear,  practical  directions  for  the  management  of  the  pregnant, 
turient,  and  puerperal  states,  as  have  been  sanctioned  by  the  most  authoritative 
ctitioners,  and  confirmed  by  the  author's  own  experience.  Collecting  his  materials 
n  the  writings  of  the  entire  body  of  antecedent  writers,  carefully  testing  their  correct- 
8  and  value  by  his  own  daily  experience,  and  rejecting  all  such  as  were  falsified  by 
numerous  cases  brought  under  his  own  immediate  observation,  he  has  formed  out  of 
m  a  body  of  doctrine,  and  a  system  of  practical  rules,  which  he  illustrates  and  enforces 
Jie  clearest  and  most  simple  manner  possible. 

OPINIONS  OF  THE  PRESS. 

Itisunquestionably  a  work  of  the  highest  excellence,  rich  in  information,  and  perhaps  fuller  in  details 
1  any  text-book  with  which  we  are  acquainted.  The  author  has  not  merely  treated  of  every  ques- 
which  relates  to  the  business  of  parturition,  but  he  has  done  so  with  judgment  and  ability." 
'i»h  and  Foreign  Medico-Chirnrgical  Review. 

The  translation  of  Dr.  Bullock  is  remarkably  well  done.  We  can  recommend  this  work  to  those 
cially  interested  in  the  subjects  treated,  and  can  especially  recommend  the  American  edition." 
'icul  Times  and  Gazette. 

The  edition  before  us  is  one  of  unquestionable  excellence.  Every  portion  of  it  has  undergone  a 
ough  revision,  and  no  little  modification  ;  while  copious  and  important  additions  have  been  made  t6 
ly  every  part  of  it.  It  is  well  and  beautifully  illustrated  by  numerous  wood  and  lithographic 
'avings,  and,  in  typographical  execution,  will  bear  a  favorable  comparison  with  other  works  of  the 
e  class." — American  Medical  Journal. 

In  the  multitudinous  collection  of  works  devoted  to  the  propagation  of  human  beings,  and  to  the 
ilf  of  parturition,  none,  in  our  estimation,  bears  any  comparison  to  the  work  of  Cazeaux,  in  its 
ro  veifoctness ;  and  if  we  were  called  upon  to  rely  alone  on  one  work  on  accouchments,  our  choice 
I J  fall  upon  the  book  before  us  without  any  kind  of  hesitation." — West.  Jour,  of  Med.  a-.d  Surgery. 
We  do  not  hesitate  to  say,  that  it  is  now  the  most  complete  and  best  treatise  on  the  subject  in  th« 
lish  language." — Buffalo  Medical  Journal. 

Ve  know  of  no  work  on  this  all-important  branch  of  our  profession  that  we  can  recommend  to  the 
ent  or  practitioner  as  a  safe  guide  before  this." — Chicago  Medical  Journal. 

Vmong  the  many  valuable  treatises  on  the  science  and  art  of  obstetrics,  the  work  of  Cazeaux  stands 
Jminent." —  St.  Louis  Med.  and  Surg.  Journal. 

M.  Cazeaux's  book  is  the  most  complete  we  have  ever  seen  upon  the  subject.  It  is  well  translated^ 
foflwjts  great  credit  upon  D-.  Bullock's  intelligence  and  industry." — M.  A.  Medico- CMrurg.  Revieu 


LINDSAY    AND    BLAKISTON  S    PUBLICATIONS. 

Cleaveland's  Pronouncing  Medical  Lexicon. 

Containing  the    Correct  Pronunciation  and  Definition  of  most  of  the 
Terms  used  by  Speakers  and  W7'iters  of  Medicine  and  the  Collateral 
Sciences.     By  C  H.  Cleaveland,  M.D.,  Member  of  the  American 
Medical  Association,  dc,  &c.     A  New  and  Improved  Edition.     $1.25 
This  Utile  work  is  not  only  a  Lexicon  of  all  the  words  in  common  use  in  Medicine, 
but  it  is  also  a  Pronouncing  Dictionary,  a  feature  of  great  value  to  Medical  Students. 
To  the  Dispenser  it  will  prove  an  excellent  aid,  and  also  to  the  Pharmaceutical  Student. 
It  contains  a  List  of  the  Abbreviations  used  in  Prescriptions,  together  with  their  mean- 
ing ;  and  also  of  Poisons  and  their  Antidotes,     It  has  received  strong  commendation 
both  from  the  Medical  Press  and  from  the  profession. 

Cohen  on  Inhalation. 

Its  Therapeutics  and  Practice.  A  Treatise  on  the  Inhalation  of  Gases, 
Vapors,  Nebulized  Fluids,  and  Powders ;  including  a  Description  of 
the  AjDparatus  employed,  and  a  Record  of  Numerous  Expjeriments, 
Physiological  and  Pathological;  with  Cases  and  Illustrations.     By  I. 

SoLis  Cohen,  M.D.     12mo.     Price, $2.50 

•'We  recognize  in  this  book  the  work  of  a  persevering  Physician  who  has  faithfully 
sti.died  his  subject,  and  added  to  its  literature  much  that  is  useful  from  his  own  expe- 
rience. Dr.  Cohen  has  given  us  briefly  and  clearly  whatever  is  valuable  in  relation  to 
the  insufilation  of  powders  in  respiratory  affections,  with  the  experimental  proofs  and 
pathological  evidence  of  their  penetration  into  the  bronchial  tubes  and  lung  tissues." 
American  Journal  of  Medical  Science,  July,  1868. 

Carson's  History  of  the  Medical  Department 

Of  the  University  of  Pennsylvania,  from  its  Foundation  in  1'I65:  icith 
Sketches  of  Deceased  Professors,  &c.  By  Joseph  Carson,  M.D., 
Professor  of  3Iateria  Medica  and  Pharmacy  in  the  University.  S2.00 

'  The  history  of  the  University  of  Pennsylvania  has  a  national  as  well  as  a  local 
incerest,  from  the  early  date  of  its  origination,  and  the  connection  with  it  of  men  of 
illustrious  public  reputation,  such  as  Drs.  Franklin,  Rush,  Physick,  Gibson,  Dewees, 
Chapman,  Wood,  &c.,  &c.  For  the  labor  and  love  which  he  has  spent  in  preparing 
tiis  most  interesting  and  valuable  work.  Prof.  Carson  has  earned  the  gratitude  of  the 
alumni  of  the  University,  and  of  all  others  interested  in  medical  education  in  tnis 
country."  —  American  Journal  of  Medical  Science. 

Dixon  on  the  Eye. 

A  Guide  to  the  Practical  Study  of  Diseases  of  the  Eye,  with  an  Outline 
of  their  Medical  and  Operative  Treatment,  with  Test  Types  and  Illus- 
trations.     Third  Edition,  thoroughly  Revised,  and  a  great  portion  Re- 
written.    By  James  Dixon,  F.R.C.S.,  Surgeon  to  the  Royal  London 
Ophthalmic  Hospital,  &c.,  &c.     In  one  volume.     Price,        .         §2.50 
"Mr.  Dixon's  book  is  essentially  a  practical  one,  written  by  an  observant  author, 
woo  brings  to  his  special  subject  a  sound  knowledge  of  general  Medicine  and  Sur- 
gery."—  Dublin  Quarif.Tly. 


LINDSAY   AND   BLAKISTON's    PUBIJCAllONS. 

Diicheiine's  Localized  Electrization. 

Translated  from  the  Third  Edition,  hy  HEHiaKRT  Tibbits,  M.D.,L.R. 
C.P.,  Land.,  Medical  Superintendent  of  the  National  Hospital  for  the 
Paralyzed  and  Epileptic.  With  92  Illustrations,  and  Notes  and  Addi- 
tions by  the  Translator.     Price,    .         .  ...         $3.00 

This  part  of  Duchenne's  great  work  is  a  translation  from  the  third  edition  now  being 
prepared  by  the  author,  and  contains  all  that  has  yet  been  printed,  and  is  published 
even  before  the  original  is  issued.  It  is  not  only  a  well-nigh  exhaustive  treatise  on 
the  medical  uses  of  Electricity,  but  it  is  also  an  elaborate  exposition  of  the  different 
diseases  in  which  Electi-icity  has  proved  to  be  of  value  as  a  therapeutic  and  diagnostic 
agent.     No  similar  treatise,  it  is  believed,  exists  in  the  English  language. 

Part  II.,  illustrated  by  chromo-lithographs  and  numerous  wood-cuts,  is  preparing. 

DiiDglison's  History  of  Medicine, 

From  the  Earliest  Ages  to  the  Commencement  of  the  Nineteenth  Century. 
By  RoBLEY  DuNGLisoN,  M.D.,  LL.D.,  late  Professor  of  Institutes  of 
Medicine  and  Medical  Jurisjjrudence  in  the  Jefferson  Medical  Gol- 
h'cje  of  Philadelphia,  &c.,  dt.c.  Now  first  Collected  and  Arranged 
from  the  Original  Manuscript,  hy  his  son,  Richard  J.  Dunglison, 
M.D.     Subscription  price,     .         .         .         .         ,         .         .         $2.50 

The  proposed  publication  of  a  posthumous  work  by  this  distinguished  author  and 
teacher  must  be  a  matter  of  general  interest  to  the  profession,  to  whose  advancement 
he  devoted  so  many  years  of  his  valuable  life.  No  writer  of  this  century  was  so  pro- 
lific in  contributions  to  medical  science,  and  the  great  success  of  his  excellent  treatises 
in  the  various  departments  of  medicine  form  a  memorable  cliapter  in  the  history  of 
American  literature.  It  forms  a  small  octavo  volume  of  280  pages,  printed  on  tinted 
paper,  handsomely  bound  in  cloth,  bevelled  boards.  It  will  be  sent  by  mail,  postage 
p.uil,  to  subscribers  who  remit  the  amount  in  advance. 

Dol)ell  on  Winter  Cougli  (^^^S^S'^^:) 

Lectures  Delivered  at  the  Royal  Hospital  for  Diseases  of  the  Chest.  By 
Horace  Dobell,  M.D.,  Senior  Physician  to  the  Hospital.  New  and 
Enlarged  Edition,  with  Cnh,red  Plates.     Octavo.     Price,    .         $3.50 

Darlington's  Flora  Cestrica;  or,  herborizing  companion. 

Containing  all  the  Plants  of  the  Middle  States,  their  Linnsean  Arrange- 
ment, a  Glossary  of  Botanical  Terms,  a  complete  Index,  &c.  By 
William  Darlington,  M  D.      Third  Edition.     Vlmo.         .         $2.25 

Dillnbero^er's  Handy-Book  of  the  Treatment 
of  Women  and  Children's  Diseases,  according 

to  the  Vienna  Medical  School. 

Part  I.  The  Diseases  of  Women.  Part  II.  The  Diseases  of  Children. 

Translated  from  the    Second  German    Edition,  by  P.  NicOL,  M.D. 
One  volume  12mo.     Price,    .......         $1.75 

"We  noticed  favorably  the  original  of  this  hand-book  some  months  ago,  and  sug- 
'  gested  that  an  English  translation  of  it,  with  notes  showing  the  main  points  wherein 
t!ie  practice  of  our  medical  schools  differs  from  that  at  Vienna,  might  be  well  received. 
Mr.  Nicol  has  now  carried  out  this  idea,  and  we  imagine  that  many  practitioners  will 
be  glad  to  possess  this  little  manual,  which  gives  a  large  mass  of  practical  hinta 
respecting  the  treatment  of  diseases  which  probably  make  up  the  larger  half  of  every- 
day practice.  The  translation  is  well  and  correctly  performed,  and  the  necessary 
explanations  of  reference  to  German  medicinal  preparations  are  given  with  propel 
fullness." —  T/ie  Practitioner. 


LINDSAY    AND    BLAKISTON's    PUBLICATIONS. 


Durkee  on  GoiiorrhcBa  and  Syphilis. 

The  Fifth  Edition,  Revised  and  Enlarged,  with  Portr^aits  and  Colored 
Illustrations.  By  Silas  Durkee,  M.D.,  Fellow  of  the  Massachusetts 
Medical  Society,  &c.,  &c.  A  Neio  and  Revised  Edition,  with  Eight 
Colored  Illustrations.     Octavo, ,         §5.00 

"Dr.  Durkee's  work  impresses  the  reader  favorably  by  the  skill  with  which  it  13 
arranged,  the  manner  in  which  the  facts  are  cited,  the  clever  way  in  which  the  author's 
experience  is  brought  in,  the  lucidity  of  the  reasoning,  and  the  care  with  which  tlie 
therapeutics  of  venereal  complaints  are  treated."  — Lancet. 

Ela'^n  on  Cerebria  and  other  Diseases  of  the 

liram.  By  Charles  Elam,  M.D.,  Fellow  of  the  Royal  College 
of  Physicians  ;  Author  of  "A  Physician's  Problems,''  (&c.,  &c.,  &c. 
Octavo.     Price, $2.50 

Fuller  on  Rheumatism,  Rheumatic  Gout,  and 

Sciatica,     third  edition,     octavo.     Price,         .         $5.00 

Flint's  Reports  on  Continued  Fever. 

With  an  Analysis  of  164  cases,  &c.,  &c.  By  Austin  Flint,  M.D.,  &c.,  &c. 
Octavo.     Price, $2.00 

Fothergill.      The    Heart   and   its    Diseases. 

With  their  Treatment.  By  J.  Milner  Fothergill,  M.D.,  Author  of 
the  Hastings  Prize  Essay  on  Digitalis,  its  Action  and  its  Use.  With 
Illustrations.     Octavo,     Price,     ......         ^5.00 

Fothergill  on  Digitalis. 

Its  Mode  of  Action  and  its  Use.  An  Inquiry  illustrating  the  Effect  of 
Remedial  Agents  over  Diseased  Conditions  of  the  HeatH,  being  the 
Hastings  Prize  Essay  of  the  British  Medical  Association  for  1870. 
By  J.  Milner  Fothergill,  M.D.     Price,    .         .         .         .         $1  25 

Fox  on  the  Human  Teeth. 

Their  Natural  History,  Structure,  and  Treatment  of  the  Diseases  to 
which  they  are  Subject.      With  250  Illustrations.  .         .         $4.00 

Gant's  Science  and  Practice  of  Surgery. 

A  Complete  Sy.?fem,  including  the  Principles  and  Practice,  by  Freder- 
ick J.  Gant,  F.R.C.S.,  Surgeon  to  the  Royal  Free  Hosjntal,  London, 
&c.,  &c.     With  470  Illustrations.     Price,     ....         $7.50 

Mr.  Gant's  book,  as  a  whole,  is  methodical,  conscientious,  learned,  and  painstaking. 
It  is  thoroughly  English  in  tone,  and  somewhat  hyperconservative  and  deferential  to 
authority.  It  is  an  excellent  compilation  of  received  opinions,  and  a  correct  guide  to 
established  modes  of  practice.  It  is  a  better  volume  for  a  surgeon  than  for  a  student's 
text-book.  It  is  a  good  guide  to  the  study  of  surgery,  and  abounds  in  valuable  facts 
and  statistics.  The  style  is  generally  clear  and  elegant.  We  advise  surgeons  who  can 
afford  it  to  buy  the  book. — New  York  Medical  Journal,  Feb.,  1872, 

Gant's  Irritable  Bladder. 

Its  Causes  and  Curative  Treatment.  Third  Edition,  Revised  and  En- 
larged.     With  New  Illustrations.     8vo.      Price,  .         .         $2.50. 


l:ni;say  and  blakiston's  publications. 

Gioss'  American  Medical  Biography  of  the 
Nineteenth  Century. 

Edited  by  Samuel  D.  Gros3,  M.D.,  Professor  of  Surgery  in  the  Jefferson 
Medical  College,  Philadelphia,  d-e.,  d'c.  With  a  Portrait  of  Benjamin 
Rush,  M.D.     Octavo $3.50 

Greenhow  on  Bronchitis,  especially  as  connected  with 

Gout,  Emphysema,  and  Diseases  of  the.  Heart.     By  E.  Headlam  Green 
HOW,  :^[.D.,  Fellow  of  the  Royal  College  of  Physicians,  &c.,  &c. 

Price,  $2.0a 

"  In  viTid  pictures  of  the  sort  of  cases  which  a  practitioner  er.coitnters  fa  his  daily  walks,  and  in  examples 
of  the  way  in  which  a  student  onght  to  turn  them  over  in  his  mind  Md  make  them  tools  for  self-improTe- 
ment.  we  have  rarely  seen  a  volume  richer."  —  iJi-i/.  and  For.  Medico- CHruyg.  Vevieu; 

Garratt's  (Alfred  C.)  Guide  for  Hosing  Medical 
Batteries. 

Shoicing  the  most  approved  Apparatus,  Methods,  and  Rules  for  the  Medical 
Employment  of  Electricity  in  the  Treatment  of  Nervous  Diseases,  d'C,  &e. 
With  numerous  Illustrations.     One  Volume,  octavo.       .        .         $2.00 

"The  large  work  on  the  same  subject,  and  by  tVie  same  author,  is  pretty  well  known  to  the  Profession,  but 
It  is  bulky  and  cumbrous,  and  by  no  means  so  practically  useful.  The  present  comparatively  brief  volume 
contains  every  thing  of  importance  in  regard  to  the  various  apparatuses  useful  to  the  Medical  Electrician 
ind  the  various  modes  of  application  for  therapeutic  purposes."  —  Lancet  and  Observer. 

Godfrey's  Diseases  of  Hair. 

A  Popular  Treatise  upon  the  Affections  of  the  Hair  System,  with  Advice 
upon  the  Preservation  and  Management  of  Hair.  By  Benjamin 
Godfrey,  M.D.,  F.R.A.S.     Price,         ..'...         $1.50 

Chapter  1.  Introduction.  2.  Anatomy  and  Physiology  of  Hair.  3.  Excess  of  Hair.  4.  Baldness.  5.  Tri- 
chionosis  Cana.  6.  Albinism.  7.  Hair  in  the  wrong  place.  8.  Vegetable  Parasitic  Diseases.  9.  Morbus 
Paxtonii.  10.  Chignon  Fungus.  11.  Plica  Polonica.  12.  Diseases  of  Color  of  the  Hair.  1.3.  Pityriasis.  14. 
Phtheiriasis.  15.  Dise.ises  of  Hair  Follicles.  16.  Trichiasis  Ciliorum.  17.  Color  of  Hair  in  relation  to  Char- 
acter and  Disease.    18.  Cleanliness.    19.  Hair  Dyes.    20.  The  Beard. 

Gardner  on  Sterility.     Its  Causes  and  Cura- 
tive Treatment.     WUh  illustrations.     Octavo.      .        $3.00 

Holden's   Manual  of  the  Dissection  of  the 

Human    Body.    WUh  Notes  and  Additions,   niustrated.   85.00 

Hillier's  Clinical  Treatise  on  the  Diseases  of 

V^niKiren.     By  Thomas  Hillier,  M.D.,  Physician  to  the  Hospital 
fir  Sick  Children,  and  to  University  College  Hospital,  &c.,  d;c.     Octavo. 

Price,  $3.00 

"Our  space  is  exhausted,  but  we  have  said  enough  to  indicate  and  illustrate  the  excellence  of  Dr.  Hilliec  3 
Tolume.  It  is  eminently  the  kind  of  book  needed  by  all  medical  men  who  w  gh  to  cultivate  clinical  HCfnv.y 
4Dd  sound  practice."  —  London  Lancet. 


LINDSAY   AND   BLAKISTON  S   PUBLICATIONS. 


Harris'  Principles  and  Practice  of  Dentistry. 

The  Tenth.  Revised  Editiun.  In  great  part  Re-icrilten,  Re-arranged, 
and  xoith  mam/  New  and  Important  Illustrations.     Including 

1.  DENTAL  ANATOMY  AND  PHYSIOLOGY.  3.  DENTAL  PUKCERY. 

2.  DENTAL  PATHOLOGY  AND  THERAPEUTICS.        4.  DENTAL  MECHANICS. 

By  Chapin  a.  Harris,  M.D.,  D.D.S.,  &c.  The  Tenth  Edition,  Revised 
and  Edited,  by  P.  H.  Austen,  M.D.,  Professor  of  Dental  Science  and 
Mechanism  in  the  Baltimore  College  of  Dental  Surgery,  with,  nearly 
400  Illustrations,  including  many  new  ones  made  especially  for  this 
edition.     Royal  Octavo,  in  Cloth,          .....         6G.50 

Leather, 7.50 

Tliis  new  edition  of  Dr.  Harris's  work  has  been  thoroughly  revised  in  all  its  parts  —  more  so  than  any  pre- 
viiiiK  edition.  So  great  have  been  the  advances  in  many  branches  of  Dentistry,  that  it  was  found  necessary 
to  rewrite  the  articles  or  subjects,  and  this  has  been  done  in  the  most  etficient  manner  by  Prof.  Austen,  for 
many  years  an  associate  and  friend  of  Dr.  Harris,  assisted  by  Prof.  Gorgas  and  Thos.  S.  Latimer,  M.D.  The 
publishers  feel  assured  that  it  will  now  be  found  the  most  complete  text-book  for  the  student  and  guide  for 
the  practitioner  in  the  English  language. 

Harris'  Dictionary,   the  third  revised  edition. 

A  Dictionary  op  Medical  Terminology,  Dental  Surgery,  and  the 
Collateral  Sciences.  The  Third  Edition,  carefully  Revised  and 
Enlarged,  by  Ferdinand  J.  S.  Gorgas,  M.D.,  D.D.S.,  Professor  of 
Dental  Surgery  in  the  Baltimore  College,  &c.,  &c. 

Royal  Octavo,  in  Cloth,     ,         .         .         .         .         .         $6.50 
Leather, 1.50 

Prof.  Gorgas  is  Dr.  Harris's  successor  in  the  Baltimore  Dental  College,  and  he  has  in  a  most  satisfactory 
manner  revised  this  edition  of  his  work,  having  added  nearly  three  thousand  new  words,  besides  making 
many  additions  and  corrections.  The  doses  of  the  more  prominent  medicinal  agents  have  also  been  added, 
and  in  every  way  the  book  has  been  greatly  improved,  and  its  value  enhanced  as  a  work  of  reference. 

Handj^'s  Text-book  of  Anatomy, 

And  Guide  to  Dissections.  For  the  Use  of  Students  of  lledicine  and 
Dental  Surgery.      With  312  Illustrations.     Octavo.     .         .         $4.00 

Hardwick's  Manual  of  Photographic  Chemis- 
try. With  Engravings.  Eighth  Edition.  Edited  and  Re-arranged  by 
G.  Dawson,  Lecturer  in  Photography,  &c.,  &c.    12mo.    In  preparation. 

Harley's  Urine  and  its  Derangements, 

With  the  Application  of  Physiological  Chemistiy  to  the  Diagnosis  and 
Treatment  of  Constitutional  as  well  as  Local  Disease.     'By  George 
Harley,  M.D.,  F.R.S.,  late  Professor  in  the  University  College,  Lon- 
don, &c.,  &c.      With  Illustrations.     One  volume.     Price,      .         $2.75 
Contents.  —  Chapter  1 .  What  is  Urine  ?     2.  Changes  in  the  Composition  of  the  Urine, 
induced  by  Food,  Drink,  Medicine,  and  Disease.     3.  Urea,  Ammontemia,  Uraemia.     4. 
Uric  Acid.     5.  Hippuric  Acid,  Chloride  of  Sodium.     6.  Urohaematin,  Abnormal  Pig- 
ments in  Urine.     7.  Phosphoric  Acid,  Phosphatic  Gravel  and  Calculi.     8.  Oxalic  Acid, 
')xaluria,  Mulberry  Calculi.     9.  Inosite  in  Urine,  Creatin  and  Creatinine,  Cholesterin, 
Cystin,  Xanthin,  Leucin,  Tyrosin.     10.  Diabetes  Melitus.     11.  Albuminuria. 

The  subject-matter  of  this  volume  was  delivered  in  a  course  of  lectures  before  the  class  at  the  University 
College,  London,  and  published  in  detached  portions  in  the  London  Medical  Times  and  Gazette,  where  tliey 
were  so  favorably  received  that  the  author  has  been  inducetl  to  revise  and  enlarge  them,  presenting  them  in 
ii  far  more  accessible  form  to  the  Profession.  Professor  Harley's  book  now  offers  facilities  for  the  study  of 
Cliysiological  and  Pathological  Chemistry,  as  applied  to  a  class  of  diseases  that  is  otherwise  very  imierfectly 
provided  for. 


LINDSAY    AND    BLAKTSTON's    PUBLICATIONS. 

Hewitt  on  Woman,    a  new,  enlarged,  and  im- 

PEOVED  EDITION.    WITH  NEW  ILLUSTRATIONS. 

The  Diagnosis,  Pathology,  and  Treatment  op  Diseases  of  Wojien, 
including  the  Diagnosis  of  Pregnmicy.  Founded  on  a  Course  of 
Lectures  delivered  at  St.  3Iary's  Hospital  Medical  School.  By  Grail y 
Hewitt,  M.D.  Lend,,  M.  R.  C.  P.,  Physician  to  the  British  Lying-in 
Hospital;  Lecturer  on  Midwifery  and  Diseases  of  Women  arid  Chil- 
dren at  St.  Mary^s  Hospital  Medical  School;  Honorary  Secreta7\i/  to 
the  Obstetrical  Society  of  London,  &c.  The  Third  Editioyi,  Revised 
and  Enlarged,  with  new  Illustrations.    Octavo,    Price  in  Cloth,    $5.00 

"     "  Leather,  6.00 

"  Ur.  Graily  Hewitt  lias  always  been  remarkable  as  one  of  the  most  careful,  well- 
reail,  thoiiglitful,  and  conscientious  Physicians  in  his  department  of  practice.  These 
qualities  give  great  literary  value  to  his  treatises;  they  are  completed  by  the  careful 
and  intelligent  application  which  he  has  made  of  his  clinical  study  of  a  large  body  of 
cases,  and  it  would  be  difficult  to  name  any  work  equally  satisfactory  in  its  completeness 
of  research,  judicious  discrimination  of  the  grounds  of  diagnosis,  and  practical  illus- 
tration of  all  that  can  throw  light  upon  the  treatment  of  the  diseases  of  women  and  the 
diagnosis  of  pregnancy,  both  under  ordinary  and  extraofdinary  cases.  It  is  one  of 
the  books  which  do  credit  to  our  literature."  —  British  Medical  Journal. 

'•We  know  of  no  work  on  the  Diseases  of  Women  which  we  can  with  greater  confi- 
dence recommend.  The  various  subjects  are  treated  with  a  fulness  and  completeness 
which  they  have  not  heretofore  received  in  this  country,  and  which  reminds  us  of  the 
exhaustive  methods  followed  in  some  of  the  best  works  of  French  and  (jenuan  medical 
writers."  —  Lancet. 

"To  younger  practitioners  the  book  will  be  found  to  present  a  great  charm  in  the-, 
calm,  thorough,  and  impartial  examinations  it  enters  into,  of  the  various  questions  that, 
are  still  sub  judice  as  to  the  pathology  and  treatment  of  some  of  the  diseases  to  which, 
women  are  subject."  —  Dublin  Quarterhj  Journal. 

"  VVe  would  heartily  commend  Dr.  Hewitt's  work  as  a  sound  guide,  not  only  in, 
diagnosis,  but  also  in  treatment."  —  Ranking  and  Radclijfe's  Half- Yearly  Ab.^tract. 

"  It  IS  especially  a  safe  and  valuable  guide  to  the  practitioner."  —  British  and  Foreign 
Medico-  Chirurgical  Review. 

"  Headers  of  the  former  editions  will  not  require  to  be  told  that  the  additions  now 
made  are  of  the  highest  possible  excellence."  —  Times  and  Gazette. 

"  It  is  one  of  the  most  useful,  practical,  and  comprehensive  works  upon  the  subject 
:n  the  English  language,  a  true  guide  to  the  student,  and  an  invaluable  means  of 
reference  for  the  teacher." — N.  Y.  Medical  Record. 

■The  second  editio.i  of  the  excellent  work  of  Dr.  Hewitt  presents  in  a  form  well 
ad.ipted  to  conduct  the  student  to  a  knowledge  of  the  Diseases  of  Womeu,  and  to  assist, 
the  young  practitioner  iu  his  study  of  these  diseases  at  the  bedside  of  the  patient  —  a 
very  full  and  clear  exposition  of  the  views  entertained  by  the  most  authoritative  teachers 
as  to  their  pathological  treatment  and  their  correct  Diagnosis.  This  commendation 
applies  especially  to  the  present  edition.  Although  the  first  edition  was  a  particularly 
excellent  exponen.t  of  the  subject,  the  second,  besides  being  brought  down  to  a  later 
date,  presents  a  fuller  and  more  systematically  arranged  account  of  the  I'alhology  of 
the  diseases  of  the  female  in  connection  with  their  treatment."  —  Amer.  Med.  Journal. 

Habershon  on  the  Diseases  of  the  Liver. 

Their  Pathology  and  Treatment.  Being  the  Lettsonian  Lectures,  deliv- 
ered at  the  3Iedical  Society  of  London,  1872,  by  S.  0.  Habershon,  M.D., 
Physician  to  Guy^s  Hospital,  &c.     Price,     ....        $1.50 . 


LINDSAY    AND    BLAKISTON'S    PUBLICATIONS. 


Headlaud  on  the  Action  o^  Medicines  in  th 

System,      sixth  americain"  edition. 

By  F.  W.  HEAr)L/V>'D,  ^I.D.,  Fellow  of  the  Royal  College  of  Physician 
&c.,  d'C.  Sixth  American  jrovi  the  Fourth  London  Edition.  Revun 
and  enlarged.     One  Volume,  octavo.     .....         83/ 

Dr.  Headland's  work  has  been  out  of  print  in  this  country  nearly  two  years,  awi>i 
ing  the  revisions  of  the  auihor,  which  now  appear  in  this  edition.  It  gives  the  ou 
scientific  and  satisfactory  view  of  the  action  of  medicine;  and  this  not  in  the  way  t 
idle  speculation,  but  by  demonstration  and  experiments,  and  inferences  almost  as  ii 
disputable  as  demonstrations.  It  is  truly  a  great  scientific  work  in  a  small  conipas 
and  deserves  to  be  the  handbook  of  every  lover  of  the  Profession.  It  has  received  il 
most  unqualified  approbation  of  the  iledical  Press,  both  in  this  country  and  in  Europ 
and  is  pronounced  by  them  to  be  the  most  original  and  practically  useful  work  that  ht 
been  published  for  many  years. 

Hille's  Pocket  Anatomist. 

Being  a  Complete  Description  of  the  Anatomy  of  the  Human  Body ;  for  th 
Use  of  Students.  By  M.  W.  Hilles,  formerly  Lecturer  on  Anatomy  an 
Physiology  at  the  Westminster  Hospital  School  of  Medicine. 

Price,  in  cloth, $1.0 

"      in  Pocket-book  form,     ......  1.2 

Heath  on  the  Injuries  and  Diseases  of  tlie  Jn  wj 

The  Jacksonian  Prize  Es^^ay  of  the  Royal  College  of  Surgeons  of  En 
land,  1867.     By  Ciirtstopher  Heath,  F.R.C.  S.,  Assistant  Surgeon 

University  College  Rospiial,  and  Teacher  of  Operative  Surgery  in  Un 
versify  College.    Containing  over  150  Illustrations.  Octavo.    Price.  .S<>.ii 

Hodge  on  Foeticide,  or  Criminal  Abortio: 

By  Hugh  L.  Hodge,  M.  D.,  Emeritus  Professor  in  the  Unvjcr.iiiy  q 
Pennsylvania.     A  Small  Pocket  Volume.       Price  in  papei-  covovs,      3 

"        flexible  cloth,      5 

This  little  book  is  intcDded  to  place  in  the  hands  of  professional  men  and  others  the  lueans  of  ar.sweri 
latisfactoiily  and  intelliijently  any  inijiiiries  that  may  be  made  of  them  in  connect.ou  wi.h  this  imjiortal 
nibject. 

Holmes'  Surgical  Diseases  of  Ipfancy  an( 

L  nilCinOOu.  By  J.  holmes,  M.A.,  S'Mgejn  to  the  Hospital  fo 
Si?.k  Children,  Sc.     Second  Edition.     Revised  and  Enlarged.     Oclav 

l^rice,  ST. 5 

Hufeland's  Art  of  Prolonging  Life.     Edited  b 

Erasmus  Wilson,  M.D.,  F  R.S.  Author  of  "^  System  of  Huma 
Anatomy;^  "Diseases  of  the  Skin,^^  &c.,  &c.     12mo.     Cloth.  $1  1 


LINDSAY   AND    BI.AKISTON  S    PUBLICATIONS. 

lewson's  Earth  in  Surgery. 

EAETH  AS  A  TOPICAL  APPLICATION  lU  SUEGEET. 
Being  a  full  Exj)osition  of  its  use  in  all  the  Cases  requiring  Tojncal  Ajypli- 
cations  admitted  in  the  Men's  and  Women's  Surgical  Wards  of  the  Fenn- 
sijlvania  Hosjntal  during  a  period  of  Six  Months  in  1869.  With  Four 
full-page  Fhoto-Eelief  Blustrations.  By  Addinell  Hewson,  M.D,,  one 
of  the  Attending  Surgeons  to  the  Fennsylvania  Sospital. 
"What  relates  to  Truth  is  greater  than  what  relates  to  Opinion."  —  Baoon. 

CONTENTS. 

Preface;  Introduction;  Histories  of  Cases;  Comments  as  to  the  Effects  of  the  Contact 
'the  Earth;  Its  Effects  on  Fain;  Its  Power  as  a  Deodorizer;  Its  Influence  over  Inflam- 
ation ;  Its  Influence  over  Putrefaction  ;  Its  Influence  over  the  Healing  Processes  ; 
lodus  Operandi  of  the  Earth;  As  a  Deodorizer  and  over  Putrefaction;  In  its  Effects  on 
jiving  Parts. 

In  One  Volume.     Price,  $2.50. 

Tliis  volume  presents  the  results  of  researches  by  the  author  into  the 
tions  of  Earth  as  a  surgical  dressing,  and  embraces  the  histories  of  over 
inety  cases  which  occurred  in  the  wards  of  the  Pennsylvania  Hospital  some 
iree  years  since,  but  whose  publication  has  been  delayed  until  now,  for  the 
juble  purpose  of  weighing  them  by  subsequent  experience,  and  of  inter- 
retiug  their  meaning  by  a  careful  study  of  the  various  subjects  which  they 
»volve. 

The  illustrations  are  introduced  for  the  purpose  of  giving  a  demonstration  as  strong 
possible  of  the  successes  attending  these  experiments,  and  are  from  photographs 
produced  by  a  method  that  would  seem  to  leave  nothing  to  be  desired  as  to  perma- 
ncy,  as  well  as  faithfulness  and  accuracy  of  representation. 

pinion  of  S.  D.  Gross,  M.D.,  LL.D.,  Professor  of  Surgery  iii  the  Jefferson  Medical  College, 

Philadelphia. 

II  have  perused  with  great  interest  and  profit  the  work  of  Dr.  Addinell  Hewson,  en- 
llled  "  Earth  as  a  Topical  Application  in  Surgei-y,"  and  regard  it  as  a  highly  valuable 
btribution  to  the  literature  of  the  profession,  destined  as  it  is  from  the  novelty  of  the 

bject  of  which  it  treats  to  attract  general  attention,  inquiry,  and  experiment.  The 
ithor  has  shown  himself  to  be  an  original  thinker,  and  the  treatment  which  he  is 
boring  to  introduce  is  worthy,  as  I  can  testify  from  personal  observation,  of  a  fair 
id  impartial  trial. 

April  6,  1872. 

xtract  of  a  Letter  from  Jos.  Pancoast,  jNI.D.,  Professor  of  Anatomy  in  Jefferson  Medical 

College,  Philadelphia. 
I  am  glad  you  have  brought  the  subject  so  perfectly  to  the  notice  of  the  profession, 
Earih  Treatment  is  destined  hereafter  to  be  one  of  the  acknowledged  resources  of 

trgery. 
March  2,  1872. 

The  cases  conclusively  show  that,  as  a  rule,  the  contact  of  the  earth  is  cooling  and 
easant  to  the  wound,  reduces  the  pain,  deodorizes,  prevents  putrefaction,  and  hastens 
e  lu'.iling  process.  These  results  are  the  highest  possible  testimonials  in  its  favor. 
0  surgeon  should  neglect  to  read  this  evidence,  the  means  being  so  simple  and  obtain- 
)le.  —  Medical  and  Surgical  Reporter,  March  23,  1872. 

Tlie  subject  is  one  of  much  practical  importance,  and  the  book  will  amply  repay 
)th  physician  and  surgeon  for  the  time  involved  in  its  careful  reading.  —  Chicago 
edical  Ejcaminer,  March  1,  1872. 


LINDSAY    AND    BLAKISTOK'S   PUBLICATIONS. 


Kirkes'  Hand-Book  of  Physiology. 

THE  SEVENTH  LONDON  EDITION. 

HAND-BOOK  OF  PHYSIOLOGY,  by  William  Senhouse  Kirkes, 
M.D.  Seventh  Edition,  edited  by  W.  Morrant  Baker,  F.R.C.S.,  Lee 
turer  on  Physiology,  <&c.,  &c.  With  241  Illustrations.  In  one  volume, 
demy-octavo,  containing  over  800  pages.    Price,  bound  in  cloth,  $5.00. 

Tbis  edition  of  Dr.  Kirkes'  Hand-Book  of  Physiology  is  fully  brought  up  to  the  times,  aud  forms  oue  of  the 
most  complete  and  convenient  Text-Books  on  the  subject,  for  the  Student  of  Medicine,  now  in  print. 

Lewiii  oil  Syphilis.     With  Illustrations. 

THE  TREATMENT  OF  SYPHILIS  with  Subcutaneous  Sublimate 
Injections.  With  a  Lithographic  Plate  illustrating  the  Mode  and  Proper 
Place  of  administering  the  Injections,  and  of  the  Syringe  used  for  the 
purpose.  By  Dr.  Georg  Lewin,  Professorat  the  Fr.-Wilh.  University, 
and  Surgeon-in- Chief  of  the  Syphilitic  Wards  and  Skin  Diseases  of 
the  Charity  Hospital,  Berlin.  Translated  by  Carl  Prcegler,  M.D., 
late  Surgeon  in  the  Prussian  Service  and  in  the  United  States  Army, 
and  E.  H.  Gale,  M.D.,  late  Surgeon  in  the  United  States  Army. 

In  One  "Volume,  small  Octavo.     Price,     .      .        .       $2.25 

Lee's:  on  Urine,   the  third  londox  edition. 

A  Guide  to  the  E  ramination  of  the  Urine.  For  the  Practitioner  and 
Student.  By  J.  Wickiia.m  Legg,  M.D.,  Member  of  the  Royal  College 
of  Physicians,  &c.,  &c.    Third  Edition.     16mo.     Cloth.    Price,  75  cts. 

"Dr.  Legg's  little  manual  has  met  with  remarkable  success,  and  the  spppdy  exhaustion  of  the  first  editioD 
has  enabled  the  author  to  make  certain  emendations  which  have  added  greatly  to  its  value.  We  can  now 
confidently  commend  it  to  the  student  as  a  safe  and  reliable  guide  to  sucli  examinations  of  the  urine  as  he 
may  be  called  upon  to  make."  —  London  Medical  Times  and  Gazette. 


Lawson's  Diseases  and  Injuries  of  the  Eye^ 
their  Medical  and  Surgical  Treatment,  with 

Illustrations.  By  George  Lawson,  F.R.C.S.,  Surgeon  to  the  Royal 
London  Ophthalmic  Hospital,  and  Assistaiit  Surgeon  to  the  Middlesex 
Hospital.     In  one  volume,  royal  12mo.     Price,     .         .         .         S2.50 

This  Manual  comprises  a  brief  account  of  all  the  Medical  and  Surgical 
Affections  of  the  Eye,  with  the  Treatment  essential  for  their  relief,  each 
subject  being  discussed  in  a  separate  section  under  its  own  peculiar  head- 
ing. The  very  favorable  notices  appended  below  attest  its  great  value  to 
the  student. 

"We  congratulate  Mr.  Lawson  on  the  production  of  such  an  excellent  work  on 
ophthalmic  diseases  as  this.  Without  depreciating  the  large  aud  valuable  treatises  on 
this  subject  that  have  recently  appeared,  we  have  long  felt  that  a  manual  was  wanted 
which  would  serve  as  a  text-book  for  students,  and  also  should  form  a  trustworthy  guide 
•for  practitioners  in  dealing  with  diseases  of  the  eye.  Well  has  IMr.  Lawson  supplied 
this  want.  He  has  described  the  various  afi'ections  of  the  eye,  briefly  but  yet  clearly, 
and  from  the  large  experience  he  has  acquired  as  surgeon  to  the  Royal  London  Oph- 
thalmic Hospital,  Moorfields,  he  has  made  his  work  thoroughly  practical.  The  profession 
will  find  this  niaiiual  just  the  sort  of  work  they  want  on  eye  diseases,  vhile  to  the 
BLudeut  it  will  be  invaluable  as  a  text-book." — British  Medical  Journal,  July  24,  1801' 


Meigs  and  Pepper  on  Children. 

rOUETH  EDITION,  ENLAEGED  AO  IMPROVED. 
The  pulilishers  have  selected  the  following  notice,  from  a  late  number  of 
the  London  Lancet,  of  the  New  Edition  of  this  work,  as  indicating,  per- 
haps, more  fully  than  any  other  of  the  numerous  favorable  criticisms  that 
have  appeared  of  it  elsewhere,  its  great  value  to  the  Practitioner  and 
Student  of  3Iedicme. 

"It  is  not  necessary  to  say  much,  in  the  way  of  criticism,  of  a  work  so  well  known 
as  Meigs  on  Diseases  of  Children,'  especially  when  it  has  reached  a  fourth  edition. 
Our  duty  is  wellnigh  restricted  to  the  point  of  ascertaining  how  far,  under  an  old 
color,  it  preserves  the  freshness  and  the  value  of  a  new  book  —  how  far  it  incorpo- 
rates what  is  new  with  what  is  old  without  unseemly  marks  of  mere  joining.  There 
is  some  advantage  in  starting  entirely  afresh,  in  being  merely  clinical,  or  in  being  very 
short,  and  limiting  one's  self  to  the  expression  of  one's  own  views  and  experience. 
But  sucli  is  not  the  nature  of  this  book,  and  the  advantages  of  it  are  different.  It  is  a 
work  of  more  than  900  good  American  pages,,  and  is  more  encyclopajdial  than  clinical. 
But  it  is  clinical,  and  withal  most  effectually  brought  up  to  the  light,  pathological  and 
therapeutical,  of  the  present  day. 

"The  book  is  like  so  many  other  good  American  medical  books  which  we  have  lately 
fiad  occasion  to  notice ;  it  marvellously  combines  a  resume  of  all  the  best  European 
literature  and  practice  with  evidence  throughout  of  good  personal  judgment,  knowl- 
edge, and  experience.  It  is  gratifying  to  see  how  our  English  authors  are  quoted,  and 
especially  how  the  labors  of  Hillier,  who  died  so  prematurely,  are  recognized.  But 
the  book  abounds  in  exposition  of  American  experience  and  observation  in  all  that 
relates  to  the  diseases  of  children.  Not  the  least  interesting  additions  to  the  volume 
are  sevei'al  extensive  tables,  exhibiting  the  mortality  in  Philadelphia  of  some  of  the 
most  common  and  fatal  diseases  in  connection  M'ith  the  variations  of  the  temperature. 
And  prepared  with  great  care  from  the  records  of  the  Board  of  Health. 

"The  thoroughly  fresh  nature  of  the  book  is  especially  seen  in  the  care  with  which 
certain  articles  have  been  written.  Such  are  those  on  Rickets  and  Tuberculosis,  Infan- 
tile Atrophic  Paralysis,  and  Progressive  Paralysis.  No  book  now  on  diseases  of  chil- 
dren is  Complete  which  does  not  treat  specially  of  constitutional  or  diathetic  diseases, 
Buch  as  rickets  and  tuberculosis,  syphilis,  &c. 

"Among  other  articles  of  great  interest  and  value  we  would  mention  those  on  Dis- 
eases of  the  Ctccum  and  Appendix  Vermiformis,  on  Indigestion  in  Children,  on  Diar- 
rhoea, on  Entero-Colitis,  on  Intussusception,  on  Chronic  Hydrocephalus,  and  on  Croup 
and  the  value  of  Tracheotomy. 

"The  difficulties  of  editing  a  new  edition  of  a  medical  book  of  some  standing  are 
not  more  fell  in  tlie  region  of  pathology  and  the  classification  of  disease  than  in  that 
of  therapeutics.  In  this  work  this  difficulty  has  been  fairly  faced  by  the  authors. 
They  liave  to  confess  to  having  changed  their  practice  very  materially  in  the  treatment 
of  acute  diseases,  to  having  given  up  mercury  in  most  inftammatory  diseases,  and  almost 
given  \ip  bloodletting.  We  recommend  the  views  of  these  authors  as  to  the  injurious 
Bffects  of  calomel  and  antimony  to  careful  consideration.  They  do  not  entirely  abjure 
the  use  of  bloodletting  in  certain  cases  of  pneumonia  and  meningitis.  Indeed,  we 
think  they  will  find  reason  in  future  editions  to  talk  a  little  less  freely  than  they  do 
about  bleeding  and  cupping  very  young  children  in  certain  circumstances  of  pneumonia, 
and  in  certain  cases  of  simple  meningitis.  With  a  few  exceptions  of  this  kind,  the 
therapeutics  are  sound  and  commendable,  great  importance  being  given  to  proper 
feeding  and  the  general  management  of  infancy  and  childhood.  It  is  due  to  authors 
of  so  much  fairness  and  experience  to  publish  widely  their  opinion  of  the  injurious 
nnd  depressing  effects  of  antimony  in  the  inflammations  of  children.  To  infants  under 
two  years  of  age  they  think  it  best  to  give  no  antimony  even  in  pneumonia.  They  do 
lot  use  tartar  emetic  at  all  in  the  cases  of  children,  but  small  doses,  such  as  the  twelfih 
of  a  grain,  of  the  precipitated  sulphuret  of  antimony,  every  two,  three,  or  four  hours, 
watching  its  effects,  and  withdrawing  it  quickly  if  symptoms  of  prostration  appear, 
perhaps  without  any  vomiting. 

"We  are  glad  to  add  this  work  to  our  library.  There  are  few  diseases  of  children 
which  it  does  not  treat  of  fully  and  wisely  in  the  light  of  the  latest  physiological, 
pathological,  and  therapeutical  science."  — London  Lancet,  July  23,  1870, 

Frice,  handsomely  bound  in  Cloth    .         .         .         .         .         .         .         $6  00 

"  "  "  Leather 7  00 

LINDSAY  &  BLAKISTON,  PUBLISHERS, 

rUIL  A  DELPHI  A. 


Mackenzie  on  Growths  in  the  Larynx. 

With  Numerous  Colored  and  other  Illustrations. 

Their  History,  Causes,  Symptoms,  Diagnosis,  Pathology,  Prognosis, 
AND  Treatment.  With  Reports  and  Analysis  of  One  Hundred  Con- 
seciUive  Gases  treated  by  the  Author  ;  and  a  Tabular  Statement  of  every 
published  case  treated  since  the  invention  of  the  Laryngoscope.  By 
MoRELL  Mackenzie,  M.D.,  Physician  to  the  Hospital  for  Diseases 
of  the  Throat,  author  of  "  The  Laryngoscope,^'  &c.    Octavo,  Price  $3.00 

"Dr.  Mackenzie  stiows  possession  of  what  has  been  well  called  '  the  complete  professional  mind.' "  —  The 
Lancet. 

"  The  most  complete  and  original  essay  on  new  formations  in  the  larynx."  —  Medical  Times  and  Gazette. 
"A  model  of  honest  and  complete  work,  and  honorable  to  British  medicine,  as  it  is  useful  to  practitioners 
of  every  country."  — British  Medical  Journal. 

"This  work  will  certainly  at  once  take  its  place  as  the  author's  chief  one,  and  on  it  alone  he  may  be  content 

to  let  his  reputation  rest The  book  is  as  complete  as  it  is  possible  to  make  it."  —  Medical  Press. 

"A  storehouse  of  sound  knowledge  on  the  subject  it  treats."  —  Practitioner. 

"The  entire  profession  is  under  a  deep  obligation  to  Dr.  Mackenzie  for  his  really  interesting, instructive, 
and  opportune  essay."  —  Edinburgh  Medical  Journal. 

"Contains  a  large  amount  of  information  which  is  of  the  very  greatest  value." —  Glasgow  Med.  Journal. 

"  Of  extreme  interest  and  value,  and  reflects  the  greatest  credit  on  Dr.  Mackenzie." — Birmingham  Med.  Rev. 

"The  essay  can  hardly  fail  to  increase  Dr.  Mackenzie's  already  honorable  position  as  an  accomplished 
laryngologist  and  instructor.  We  trust  that  the  work  will  find  readers,  not  only  among  physicians  espe- 
cially interested  in  the  subject  of  which  it  treats,  but  among  general  practitioners  as  well.  They  will  find  it 
particularly  free  from  the  technicalities  which  often  make  works  on  special  subjects  dull  reading."  —  Anier. 
Journal  of  Medical  Science. 

"  As  a  work  which  contains  much  that  is  new  and  cannot  be  found  elsewhere,  we  bespeak  for  it  a  welcome 
in  America.  It  contains  the  most  perfect  and  satisfiictorj'  tabular  record  that  any  laryngoscopist  has  ever 
presented  to  the  profession."  —  iVew)  Tbi-li  Medical  Journal. 

"  It  is  not  in  mere  compliment  that  we  say  that  no  practitioner  engaged  in  the  surgical  treatment  of  laryn- 
geal tumors  can  afford  to  forego  the  study  of  Dr.  Mackenzie's  volume."  — New  York  Medical  Becord. 

"This  is  certainly  the  chefd'ceuvre  of  Dr.  Mackenzie's  productions The  last  and  decidedly  the  best 

section  of  the  book  is  upon  treatment.     It  is  esjiecially  commendable  for  the  perspicuity  and  fairness  with 
which  it  discusses  the  comparative  merits  of  the  different  operations  and  instruments."  —  Phila.  Med.  Times. 

Mackenzie  on  the  Laryngoscope  in  Diseases 

Of  the  Throat,  with  an  Appendix  on  Bhinoscopy,  and  an  Essay  on 
Hoarseness,  and  Loss  of  Voice.  With  additions,  by  J.  SoLis  Cohen, 
M.D.,  Author  of  "  Lihalation,  Its  Therapeutics  and  Practice,'"  &c.  Il- 
lustrated by  two  Lithographic  Plates,  and  51  Engravings  on  Wood. 
Price, $3.00 

"  The  Use  of  the  Laryngoscope  in  Diseases  of  the  Throat,  and  Essays  on  Hoarseness, 
&c.,  are  two  monographs  of  first-rate  merit.  Dr.  Mackenzie's  Essays  wouM  do  honor 
to  any  place  ;  and  he  has  used  the  opportunities  afforded  to  diligence  and  skill  to  make 
solid  and  enduring  contributions  to  sciencfe  and  practice.  Both  works  are,  througliout, 
models  of  honest  and  complete  work,  and  are  honorable  to  medicine,  as  they  are  useful 
to  practiti<iners  of  every  country.  The  completeness  of  the  clinical  records,  the  abun- 
dant graphic  illustrations,  and  the  fulness  of  bibliographical  references,  are  excellent 
features."  —  British  Medical  Journal. 

Mackenzie's  Pharmacopoeia  of  the  Hospital 

For  Diseases  of  the  Throat,  containing  upwards  of  150  Formulce  for 
Gargles,  Throat  Gollyria,  Lozenges,  Inhalations,  &c.,  adapted  for 
Throat  Diseases.  Based  on  the  British  Pharmacopoeia  of  18G7.  In 
Cloth, $1.25 


LINDSAY   AND   BLAKISTON  S    PUBLICATIONS. 

Meadows'  Maiuial  of  Midwifery,    a  New  Text-Book. 

Including  the  Signs  and  Symptoms  of  Pregnancy,  Obstetric  Operations, 
Diseases  of  the  Puerperal  State,  &c.,  &c.  By  Alfred  MEi»DOWS, 
M.D.,  Member  of  the  Royal  College  of  Physicians,  &c.,  &g.  First 
American  from  the  Second  London  Edition.  With  numerous  Illustra' 
tions.     Price, $3.00 

"Those  who  read  the  first  edition  of  tliis  work  will  bear  us  out  in  thinking  tliat  Dr.  Meadows's  Manual 
forms  one  of  the  most  convenient,  practical,  and  concise  books  yet  published  on  the  subject.  It  was  espe- 
cially good  as  a  student's  manual,  and  the  author  has,  iu  his  second  edition,  sought  to  make  it  of  equal  value 
to  the  practitioner.  The  part  which  treats  of  obstetric  operations  has  been  well  revised,  and  has  received 
numerous  additions,  and  the  several  chapters  on  Unnatural  and  Complex  Labors  likewise  comprise  much 
new  matter.  Upwards  of  ninety  new  engravings  have  been  inserted  in  this  edition,  and,  with  a  view  to 
facilitate  reference,  the  author  has  furnished  it  with  a  very  full  and  complete  table  of  contents  and  index. 
We  can  cordially  recommend  this  manual  as  accurate  and  practical,  and  as  containing  in  a  small  compass 
a  large  amount  of  the  kind  of  information  suitable  alike  to  tlie  stuilent  and  practitioner." — London  Lancet, 
May  6,  1871. 

"This  new  edition  of  a  book  which  was  at  once  recognized  as  a  good  manual,  is  a  considerable  improve- 
ment on  its  predecessor.  It  is  eminently  a  book  which  will  teach  the  student.  .  .  .  Not  merely  is  the  prac- 
tical treatment  of  Labor,  and  also  of  the  Diseases  and  Accidents  of  Pregnancy,  well  and  clearly  taught,  but 
the  anatomical  machinery  of  parturition  is  more  effectively  explained  than  in  any  other  treatise  that  we 
remember;  and  besides  this,  the  book  is  honorably  distinguished  among  manuals  of  Midwifery  by  the  ful- 
ness with  which  it  goes  into  the  subject  of  the  sti-ucture  and  development  of  the  ovum.  Dr.  Meadows  has 
done  good  service  in  giving  a  clear  account  of  this  subject  in  a  very  short  space,  yet  with  sufficient  fulness. 
On  all  questions  of  treatment,  whether  by  medicines,  by  hygienic  regimen,  or  by  mechanical  or  operative 
appliances,  this  treatise  is  as  satisfactory  as  a  work  of  manual  size  could  be ;  and  altogether,  students  aud 
practitioners  can  hardly  do  better  than  adopt  it  as  their  vade-mecum."  —  The  Practitioner, 

Maxson's  Practice  of  Medicine. 

By  Edwin  R.  Maxson,  M.D.,  formerly  Lecturer  on  the  Practice  of 

3Ie<iicine  in  the  Geneca  Medical  College,  &c.  .         .         $-1.00 

Morris  on  Scarlet  Fever. 

Its  Pathology  and  Therapeutics.  By  Casper  Morris,  M.D.,  Fellow  of 
the  College  of  Physicians  of  Philadelphia,  ({:c.     .  .  .  $1.50 

Mendenhall's  Medical  Student's  Vade  Mecum. 

A  Gompendiinn  of  Anatomy,  Physiology,  Chemistry,  the  Practice  of 
Mi'dicine,  Surgery.  Obstetrics,  Diseases  of  the  Skin,  Materia  Medica, 
Pharntacy,  Poisons,  <&(,-.,  £c.  By  George  ^NIendenhall,  M.D.,  Pro- 
fessor of  Obstetrics  in  the  Medical  College  of  Ohio,  &c.,  &c.  Tenth 
Edilion,  lievi!<ed  and  Enlarged,  with.  224  Illustrations.  .  S2.50 

Penns3dvania  Hospital  Reports.    Edited  by  a  com- 

mitfee  of  the  Hospital  Staf,  J.  M.  DaCosta,  M.D.,  and  William 
Hunt,  M.I).      Vols.  1  and  2,  for  18G8  and  1869,  each  volume  contain- 
ing  uptcards  of  Twent)-   Original  Articles,  by  former  and  p>resent 
Members  of  the   Staff,  now  eminent  in  the  Profession,  with  Litho- 
graphic and  other  Illustrations.     Price  per  volume,      .         .         $4.00 
At  last,  however,  the  work  has  been  commenced,  the  Philadelphia  Physicians  being 
llio  first  to  occupj'  this  field  of  usefulness.     The  first  Picports  were  so  favorably  re- 
ceived, on  both  sides  of  the  Atlantic,  that  it  is  hardly  necessary  to  speak  for  them  the 
universal  welcome  of  which  they  are  deserving.     The  papers  are  all  valuable  contri 
butions  to  the  literature  of  medicine,  reflecting  great  credit  upon  their  authors.     The 
work  is  one  of  which  the  Pennsylvania  Hospital  may  well  be  proud.     It  will  do  much 
icward  elevating  the  profession  of  this  country.  —  American  Journal  of  Obstetrics. 


No.  5.   The  Lymphatics  or  Absorbents. 
No.  6.   The  Digestive  Organs. 
No.  7.   The  Brain  and  Nerves. 
No.  8.  The  Organs  of  Sense  and  Voice. 
No.  9.  The  Textures.  —  Microscopic  Struc- 
tures. 


Marshall's  Physiological  Dijigranis. 

LIFE-SIZE,  AND  BEAUTIFULLY  COLORED, 

On  account  of  their  large  size  and  the  great  distinctness  of  the  figures  on  them,  there 
has  been  a  growing  demand  in  this  country  for  these  Maps  for  the  Lkciure  Room  and 
for  lecturing  from  in  Medical  as  well  as  other  Schools.  In  order  to  supply  this 
demand  on  more  favorable  terms,  we  have  recently  completed  an  arrangement  with  the 
publishers  in  London,  by  which  we  can  sell  them  to  the  trade  and  others  at  a  reduced 
price  and  on  better  terms  than  heretofore. 

The  series,  illustrating  the  whole  Human  Body,  are  life-size,  each  map  printed  on  a 
single  sheet  of  paper,  made  specially  for  the  purpose,  1  feet  long  and  Z  feet  9  inches  broad^ 
colored  in  fac-simile  of  the  Original  Drawings.     There  are  nine  diagrams,  as  follows* 

No.  I.  The  Skeleton  and  Ligaments. 

No.  2.  The  Muscles  and  Joints,  with  Ani- 
mal Mechanics. 

No.  3.  The  Viscera  in  Position.  —  The 
Structure  of  the  Lungs. 

No.  4.  The  Heart  and  principal  Blood- 
vessels. 

Prepared  under  the  direction  of  John  Marshall,  F.R.S.,  F.E.C.S.,  Pro- 

fessor  of  Surgery,  University  College,  and  Surgeon  to  University  College 

Hospital. 

Price  of  the  Set,  Nine  Maps,  in  Sheets,  ....  $50.00 
"  "  "  "  handsomely  Mounted  on 

Canvas,  with  Rollers,  and  Varnished, $80.00 

Though  designed  more  especially  for  purposes  of  general  education,  supplying  an 
acknowledged  necessity  of  modern  teaching,  these  diagrams  will  be  found  not  inappli- 
cable to  the  requirements  of  professed  Medical  Schools,  affording,  as  they  do,  a  correct 
preliminary  view  of  the  various  systems  and  organs  in  the  human  body.  For  Public 
School  Purposes,  for  Lectures  at  Literary,  Scientific,  and  other  Institutes,  they  will 
be  found  invaluable;  and  also  to  students  of  Artistic  Anatomy,  imparting,  as  they  do, 
when  suspended  on  the  walls  of  the  Lecture-hall,  School-room,  or  Studio,  a  familiar 
acquaintance  with  the  whole  human  system. 

An  Explanatory  Key  to  the  Physiological 

Diagrams.  By  John  Marshall,  F.R.S.,  F.R.C.S.,  &c.  Octavo. 
Paper  covers 50  cts. 

Description  of  the  Human  Body. 

Its   Structure    and   Functions.      Illustrated    by   Physiological  Diagrams, 

Designed  for  the   Use  of  Teachers  in  Schools  and  Young  Men  destined 

for  the  Medical  Profession,  and  for  popular  Instruction  generally.     New 

Edition.     By  John  Marshall,  F.R.S.,  F.R.C.S.,  Professor  of  Surgery 

University  College,  and  Surgeon  to  the  University  College  Hospital. 

The  work  contains  260  quarto  pages  of  Text,  bound  in  cloth,  and  193  Colored 
Illustrations,  arranged  in  Nine  Folio  Diagrams,  carefully  colored  and 
reduced  from  Prof.  Marshall's  large  tvork.     2  vols.     Cloth.       .     SIO.OO 

Murpliy's  Review  of  Chemistry  for  Students. 

Adapted  to  the  Courses  as  Taught  in  the  Principal  Medical  Schools  in 
the  United  States.    By  John  G.  Murphy,  M.D.        .        .        .  $1 .25 


LINDSAY    AND    BLAKISTON  S    PUBLICATIONS. 


I 


Martin's  Manual  of  Microscopic  Mounting. 

Wilh  Illiistralions  on  Stone  and  Wood.     8vo.     Preparing. 

Macnamara's  Manual  of  the  Diseases  of  the 

iliye.  With  Colored  Plates.  Second  Edition,  carefully  Revised, 
with  Additions,  &g.,  &c.     Octavo.     Preparing. 

Morfit's  Chemical  and  Pharmaceutical  Man- 
ipulations. A  Manual  of  the  Chemical  and  Chemico- Mechani- 
cal Operations  of  the  Laboratory.     By  Campbell  Morpit,  Professor 

of  Analytic  and  Applied  Chemistry  in  the  University  of  Maryland. 
New  Edition,  with  over  500  Illustrations.     Preparing. 

Miller  on  Alcohol,  and  Lizars  on  Tobacco. 

Alcohol:  Its  Place  and  Power.  B}"  James  Miller,  F.R  S.E.,  Professor 
of  Surgery  in  the  University  of  Edinburgh,  President  of  the  Medico- 
Chiru7-gical  Society,  Author  0/ Miller's  Principles  and  Practice  of 
Surgery,  &c.,  &c. —  The  Use  and  Abuse  of  Tobacco.  By  John  Lizars, 
late  Professor  of  Sm'gery  to  the  Moyal  College  of  Surgeons,  &c.,  (f;c. 
The  Two  Essays  in  One  Volume.     12mo.    ....         $1.00 

Ott  on  Soaps  and  Candles. 

Including  the  Most  Recent  Discoveries  in  the  Manufactxire  of  all  kinds 
of  Ordinary  Hard,  Soft,  and  Toilet  Soajys,  and  of  Tallow  and  Com- 
fjosiie  Candles.  By  Adolph  Ott,  Practical  and  Analytical  Chemist. 
12mo.      With  Illustrations $2.50 

Overman's  Practical  Mineralogy,  Assaying 

and  Mining.  WUh  a  Description  of  the  Useful  Minerals,  and 
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Frederick  Overman,  Mining  Engineer,  &c.     12mo.  .        $1.25- 

Piesse's  Whole  Art  of  Perfumery. 

And  the  Methods  of  Obtaining  the  Odors  of  Plants;  the  Manufacture  tf 
Perfumes  for  the  Handkerchief,  Scented  Powders,  Odorous  Vinegars, 
Dentifrices,  Pomatums,  Cosmetics,  Perfumed  Soaps,  &c.;  the  Prepa- 
ration of  Artificial  Fruit  Essences,  &c.  By  G.  W.  Septimus  Piesse,. 
Analytical  Chemist.  Second  American,  from  the  Third  London 
Edition.     12mo.      With  Illustrations $3.00 

Piggott  on  Copper  Mining  and  Copper  Ore. 

Containing  a  full  Description  of  some  of  the  Principal  Copper  Mines- 
of  the  United  States,  the  Art  of  Mining,  the  Mode  of  Preparing  the 
Ore  for  Market,  &c.,  &c.     By  A.  Snowden  Piggott,  M.D.,  Practical 
Chemist.     12nio $1.50^ 


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Pereira's  Physician's  Prescription  Book. 

Cohtaining  Lists  of  Terms,  Phrases,  Contractions,  and  Abbreviations,  used 
in  Prescriptions,  with  Explanatory  Notes,  the  Grammatical  Constructicna 
of  Prescriptions,  Pules  for  the  Pronunciation  of  Pharmaceutical  Terms, 
A  Prosodiacal  Vocabulary  of  the  Names  of  Drugs,  etc.,  and  a  scries  of 
Abbreviated  Prescriptions  illustrating  the  use  of  the  preceding  terms,  etc. ; 
to  tvJiich  is  added  a  Key,  containing  the  Prescriptions  in  an  unabbreviated 
Form,  tvith  a  Literal  Translation,  intended  for  the  uxe  of  Medical  and 
Pharmaceutical  Students.  By  Jonathan  Pereira,  M.D.,  F.R.S.,  etc. 
From  the  Fifteenth  London  Edition. 

Price,  in  cloth, $1.25 

"      in  leather,  with  Tucks  and  Pocket,       .         .         .  1.50 

This  lit'le  work  has  passed  through  fifteen  editions  in  London  and  several  in  this 
country.  The  present  edition  of  which  this  is  a  reprint  has  been  carefully  revised 
and  many  additions  made  to  it.  Its  great  value  is  proven  both  by  its  large  sale  and 
the  many  favorable  notices  of  it  in  the  Medical  Press. 

Paget's  Surgical  Pathology.  Third  London  Edition. 

Lectures  delivered  at  the  Royal  College  of  Surgeons  of  England,  by  James 
Paget,  F.R.S.,  Surgeon  to  St.  Bartliolomeio''s  Hospital,  rfec,  &c.  Third 
London  Edition,  edited  and  Revised  by  William  Turner,  M.D.,  Lond. 
Professor  of  Anatomy  in  the  University  of  Edinburgh,  &c.  One  volume. 
Octavo,  with  numerous  Illustrations.     Price,  ....     $7.50 

A  new  and  revised  edition  of  Mr.  Paget's  Classical  Lectures  on  Surgical  Pathology 
needs  no  introduction  to  our  readers.  Commendation  of  it  would  be  as  superiiuous  as 
criticism  would  be  out  of  place.  Suffice  it  to  say  that  almost  every  page  bears  evidence 
that  the  present  edition  has  been,  as  the  author  mentions  in  his  preface,  "  carefully  re- 
vised," from  a  clinical  point  of  view  by  himself,  and  from  the  pathological  by  his  only 
less  distinguished  editor,  Professor  Turner.  The  latest  observations  of  pathologists  in 
all  parts  of  the  world  have  received  due  attention,  and,  as  a  consequence,  the  lectures 
in  their  present  shape  are  not  only,  as  Mr.  Paget  modestly  hopes  they  may  be  «on- 
sidered,  "better  than  they  were,"  but  probably  the  very  best  to  which  the  student  of 
pathology  can  resort.  —  American  Medical  Journal. 

Prince's  Plastic  and  Orthopedic  Surgery. 

Containing, 

1.  A  Report  on  the  Condition  of  and  Advances  made  in,  Plastic  and 

Orthopedic  Surgery  up  to  the  Year  1871. 

2.  A   Neu)  Classification  and  Brief  Exposition  of  Plastic  Surgery. 

With  numerous  Illusti-ations. 

3.  ORTHorEDics:  A  Syxtematio  Work  upon  the  Prevention  and  Cure 

of  Deformities.      With  numerous  Illustrations. 
In  one  volume,  Octavo.     Price,     ......         $4.50 

•'This  is  a  good  book,  upon  an  important  practical  subject;  carefully  written, 
ubuudiintly  ilULSirated,  and  well  printed.  It  goes  over  the  whole  ground  of  deformi- 
ties of  all  degrees  —  from  cleft-palate  and  club-foot,  to  spinal  curvatures  and  ununited 
fractures.  It  appears,  moreover,  to  be  an  original  book,  so  far  as  one  chiefly  of  com- 
pilation can  be  so.  Such  a  book  was  wanted,  and  it  deserves  success."  —  Mtd.  and 
Su-</.  Repor'tr. 


LINDSAY    AND    BLAKISTON  S    PUBLICATIONS. 


Rindfleiscli's    Text-Book     of    Pathological 

Histology.     208  Illustrations. 

A7i  Introduction  to  the  Sludij  of  Pathological  Anatomy.  By  Dr.  Edward 
RiNDFLEisCH,  0.  0.  Profes^or  of  Pathological  Anafomi/  in  Bonn. 
Tranalated  fi'om  the  Second  German  Edition,  by  Wm.  C  Kloman, 
M.D.,  assisted  by  F.  T.  Miles,  M.D.,  Profesaor  of  Anatomy,  Univer- 
sity of  Maryland,  dec,  &c.  Containing  208  Elaborately  Executed 
Microscopical  Illustrations.     Octavo.     Price,  bound  in  Cloth,     8fi.OO 

•'  Leather,  7.00 

For  the  first  time  since  microscopical  anatomy  has  become  the  basis  of  a  true  pathol- 
ogy, American  students,  and  indeed  we  may  say  English  students,  have  access  to  a. 
suitable  text-book  in  their  own  language.  Heretofore  the  opportunity  of  studying 
patbolojry  has  been  limited  to  a  comparative  few  who  were  familiar  with  the  German 
ami  French.  But  in  the  translation  of  Rindfleisch,  we  have  furnished  us  not  merely 
an  excellent  guide,  but  actually  the  best  which  could  be  made  available,  either  to 
practitioner  or  student.  It  would  be  impossible,  and  it  is  indeed  needless,  to  present 
a  remnie  of  its  contents.  The  volume  is  a  faithful  exposition  of  the  present  state  of 
pathological  histology;  each  subject  is  fully  and  systematically  treated,  and  may, 
therefore,  be  studied  independently  of  any  relation  to  others.  The  work  of  the  trans- 
lators has  been  well  done,  and  although  a  few  idiomatic  sentences  have  crept  into  the 
text  which  are  not  very  intelligible,  they  scarcely  impair  the  value  of  the  work.  No 
physician  or  student  should  be  without  it. — Philadelphia  Medical  Times,  Feb.  1,  1872. 

Richardson's  Practical  Treatise  on  Mechani- 
cal  JJentlStry.     second  edition,  much  enlarged. 

By  Joseph  Richardson,  D.D.S.,  Professor  of  Mechanical  Dentistyy  in 
the  Ohio  College  of  Dental  Surgery,  &c.  With  over  150  beautifully 
executed  Illustrations.     Octavo.     Leather.  .         .         .         $4.50 

This  work  does  infinite  credit  to  its  author.  Its  comprehensive  style  has  in  no  way 
interfered  with  most  elaborate  details  where  this  is  necessary;  and  the  numerous  and 
beautifully  executed  wood-cuts  with  which  it  is  illustrated  render  this  volume  as  at- 
tractive as  its  instructions  are  easily  understood. — Edinburgh  Med.  Journal. 

The  scope  of  the  whole  work  is  thoroughly  carried  out,  and  to  any  one  desiring  a 
theoretical  knowledge  of  Dental  Mechanics,  Dr.  Richardson's  book  will  be  found  a  most 
efficient  guide.  —  British  and  Foreign  Medico- Chirurg.  Review. 

Reynokls'  Lectures  on  the  Clinical  Uses  of 

Electricitij,  Delivered  at  the  University  College  Hospital.   By  J.  Russell 
Reynolds,  M.D.,  F.R.S.,  Professor  of  the  Principles  and  Practice 
of  Medicine,  University   College,  London,  editor  of  "A  System  of 
Medicine,''''  <kc.,  &c.     Post  octavo.     Price,    ....         $L50 
This  liandy  little  book  conveys  a  great  deal  of  information  in  small  bulk  and  in  clear 
readable  EnglLsli.     It  is  so  terse  and  compressed,  that  any  quotations  from  the  context 
could  only  feebly  convey  the  highly  practical  and  generally  useful  nature  of  the  in- 
struction it  contains.  —  Edinburgh  Medical  Journal,  January,  1872. 

Reese's  Analogy  of  Physiology.  Price,  .     um 


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Radcliffe's  Lectures  on  Epilepsy,  Pain,  Pa- 
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And  certain  other  Disorders  of  the  Nervous  System.  Bj  Charles 
Bland  Radcliffe,  M.D.,  Fellow  of  the  Royal  College  of  Physicians 
of  London^  &c.,  &c.     With  Illustrations $2.00 

Rigby's  Obstetric  Memoranda,  fourth  edittox. 

Edited  by  Alfred  Meadows,  M.D.,  Author  of  "A  Manual  of  3Iid- 
wifery,"  &c.,  (60.     Price,    ...;...         50  cts. 

Robertson's  Manual  on  Extracting  Teeth. 

Founded  on  the  Anatomy  of  the  Farts  involved  in  the  Operation;  the 
Kinds  and  Proper  Construction  of  the  Instruments  to  be  used;  the 
Accidents  liable  to  occur  from  the  Operation,  and  the  Proper  Reme- 
dies. By  Abraham  Robertson,  D.D.S.,  M.D.  Second  Edition, 
Revised  and  Improved.     With  Illustrations.        .         .  $1.50 

Rilil  &  O'Connor's  Physician's  Diary, 

Monthly,  Semi-Annual,  and  Annual  Journal  and  Cash-Book  Combined^ 
The  Fourth  Revised  Edition.  A  large  folio  volume,  with  printed 
Heads,  Index,  &c.,  &c.     Bound  in  full  leather.     Price,     .        .     $7.50 

Renouard's  History  of  Medicine. 

From  its  Origin  to  the  Nineteenth  Century.  By  P.  Y.  Renouard,  M.D. 
Translated  from  the  French  by  G.  G.  Comegys,  M.D.,  Professor  of 
the  Institutes  of  Medicine,  &c.     Octavo.     Price,  .         .         .         $4.00 

Reports  on  the  Progress  of  Medicine  and 

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Women  and  Children,  Materia  Medica,  &c.  Edited  by  Drs.  Power, 
Holmes,  Ainstie,  and  Barnes,  for  the  Sydenham  Society  of  London 
Octavo.     Price, $2.00 

Ross.     The  Graft  Theory  of  Disease. 

Being  an  Application  of  Mr.  Darwin^s  Hypothesis  of  Pangenesis  to  the 
Explanation  of  the  Phenomena  of  the  Zymotic  Diseases.  By  James 
Ross,  M.D.     Demy  Octavo.     Price, $4.00 

Ryan's  Philosophy  of  Marriage. 

In  its  Social,  Moral,  and  Physical  Relations;  with  an  Account  of  the  Dis- 
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Member  of  the  Royal  College  of  Physicians.     12mo.  .         .         $1.00 

Reese's  American  Medical  Formulary.      $1.50 


LINDSAY    AXD    BLAKISTOx's    PUBLICATIONS. 


Sanderson  and  Foster's  Handbook  for  the 

-Laboratory.  Being  PravUcal  Exercises  for  Students  in  Ph;/- 
siologi/  and  Histologi/.  Edited  b//  Professors  Burdon-Sandkrsox  iiiul 
Michael  Foster,  with  the  co-operation  0/ Dr.  Brunton  (^for  Phi/si- 
ology)  and  Dr.  E.  Klein,  of  Vienna,  {for  Histology.)  In  one  voliune, 
octav^o,  ivith  numerous  Illustrations  from  'Original  Drawings.  Pre- 
paring. 

Stille's  Epidemic  Meningitis; 

0>;  Cerebrospinal  Meningitis.  By  Alfred  Stille,  M.D.,  Professorof 
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"This  monograph  is  a  timely  publication,  comprehensive  in  its  scope,  and  present- 
ing within  a  small  compass  a  fair  digest  of  our  existing  knowledge  of  the  disease,  par- 
ticularly acceptable  at  the  present  time.  It  is  just  such  a  one  as  is  needed,  and  may 
be  taken  as  a  model  for  similar  works."  —  Am.  Journal  Med.  Sciences. 

Stille's  Elements  of  General  Pathology. 

A  Practical  Treatise  on  the  Causes,  Forms,  Symptoms,  and  Results  of 
Disease.     Second  Edition  preparing. 

Sweringen's  Pharmaceutical  Dictionary. 

A  Lexicon  of  Pharmaceutical  Science.     In  preparation. 

Schultze's  Lecture  Diagrams  for  Instruction 
in  Pregnancy  and  Midwifery.    20  piates  of  the 

largest  Imperial  size,  p)rinted  in  colors.  Drawn  and  Edited  with 
Explanatory  Notes  by  Dr.  B.  S.  Schultze,  Professor  of  Midicifery 
at  the  University  of  Jena.      With  4to  volume  of  letter-press.        $15.00 

Sansom  on  Chloroform. 

Its  Action  and  Administration.  By  Arthur  Ernest  Sansom,  M.B., 
Physician  to  King^s  College  Hospital,  &c  ,  &c.     12mo.         .         $2.00 

"  The  work  of  Dr.  Sansom  may  be  characterized  as  most  excellent.  Written  not 
alone  from  a  theoretical  point  of  view,  but  showing  very  considerable  experimental 
study,  and  an  intimate  clinical  acquaintance  with  the  administration  of  these  remedies, 
—  passing  concisely  over  the  whole  ground,  giving  the  latest  information  upon  every 
point,  —  it  is  just  the  work  for  the  student  and  practitioner." — Amer.  Medical  Journal. 

Scanzoni  on  Women. 

A  Practical  Treatise  on  the  Diseases  of  the  Sexual  Organs  of  Women. 
Translated  from  the  French.  By  A.  K.  Gardner,  A.M.,  M.D.,  &c. 
With  Illustrations.     Octavo, $5.00 

Stokes  on  the  Diseases  of  the  Heart 

And  the  Aorta.  By  William  Stokes,  Regius  Professor  of  Physic  in 
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LINDSAY   AND    BLAKISTON's   PUBLICATIONS. 


THOMAS  HAWXES  TANNER'S  WORKS. 

"  The  leading  feature  of  Dr.  Tanner'' s  hooks  is  their  essential li/  practical  character." 

London  Lancet. 

Tanner's  Practice  of  Medicine. 

FIFTH  AMERICAN,  FROM  THE  SIXTH  LONDON  EDITION. 

lietmed,  much  Enlarged,  and  thoroughly  brought  up  to  the  present  time. 
With  a  complete  Section  on  the  Diseanes  Peculiar  to  Women,  an  exten- 
sive Appendix  of  Formidse  for  Medicines,  Baths,  &c.,  &c.  By  Thomas 
Hawkes  Tanner,  M.D.,  Fellow  of  the  Royal  College  of  Physicians, 
&c.     Royal  Octavo,  over  1100  pages.     Price,  bound  in  Cloth,     $6.00 

"         Leather,  7-00 

Thero  is  a  common  character  about  the  writings  of  Dr.  Tanner  —  a  character  which  constitutes  one  of  their 
chief  values:  they  are  all  esseatially  and  thoi-oughly  practical.  Dr.  Tanner  never,  for  one  moment,  allows 
this  utilitarian  end  to  escape  his  mental  view.  He  aims  at  teaching  how  to  recognize  and  how  to  cure  dis- 
ease, and  in  this  he  is  thoroughly  successful.    .   .    .    It  is.  Indeed,  a  wonderful  mine  of  knowledge. —  Midicnl 

Tiiin's. 

Tanner's  Practical  Treatise  on  the  Diseases 
of  Infiincy  and  Childhood,   price,  ss.so. 

THIRD  AMERICAN  EDITION,  REVISED  AND  ENLARGED. 

By  Alfred  Meadows,  M.D.,  London,  M.R.C.P.,  Physician  to  the  Eos- 
pital  for  Womeri  and  to  the  Gener'al  Lying-in  Hospital,  &c.,  (&c. 

This  book  of  Dr.  Tanner's  has  been  much  enlarged  and  the  plan  altered  by  Dr.  Meadows.  As  it  now  stands 
it  is  probably  one  of  the  most  complete  in  our  language.  It  no  longer  deals  with  children's  diseases  only, 
but  includes  the  peculiar  conditions  of  childhood,  both  normal  and  abnormal,  as  well  as  the  therapeutics 
specially  applicable  to  that  class  of  patients.  The  articles  on  Skin  Diseases  have  been  revised  by  Dr.  Tilbury 
Fox,  and  those  on  Diseases  of  the  Eye  by  Dr.  Brudenell  Carter,  both  gentlemen  distinguished  in  these  spe- 
cialties.—^/cdicai  'rimes  and  Gazette. 

Tanner's  Index  of  Diseases  and  their 

Ireatnient.      WUh  upwards  0/500  Formulse  for  Medicines, 
Baths,  Mineral  Waters,  Climates  for  Livalids,  &c.,  &c.    Octavo,  $3.00 

To  the  busy  practitioner  it  must  be  an  advantage  to  see  at  a  glance,  on  a  quarter  or  half  a  page,  the  prin- 
cipal point  in  any  disease  about  which  he  may  wish  to  have  his  memory  refreshed  or  his  mind  stimulated. 
It  will  be  found  a  most  valuable  companion  to  the  judicious  practitioner. —  Tlte  Lancet. 

Tanner's  Memoranda  of  Poisons. 

A  New  and  much  Enlarged  Edition.     Price,        ...       75  cts. 

This  manual  is  intended  to  assist  the  practitioner  in  the  diagnosis  and  treatment  of  poisoning,  and  especially 
to  prevent  his  attributing  to  natural  disease  symptoms  due  to  the  administration  of  deadly  drugs. 

Taft's  Practical  Treatise  on  Operative  Den- 

A  NEW  EDITION,  THOROUGHLY  REVISED. 


tistry. 


By  Jonathan  Taft,  D.D.S.,  Professor  of  Operative  Dentistry  in  the 
Ohio  College  of  Dental  Surgery,  &c.  Second  Edition,  thoroughly  Re- 
vised, with  additions,  and  fully  brought  up  to  the  jji^esent  state  of  the 
Science.    Containing  over  100  Illustrations.    Octavo.    Leather,    3-1.50 

Professor  Taft  has  done  good  service  in  thus  embodying,  in  a  separate  volume,  a  comprehensive  view  of 
Operative  Dentistry.  This  gentleman's  position  as  a  teacher  must  have  rendered  him  fomiliar  with  the  most 
recent  views  which  are  entertained  in  America  on  this  matter,  while  his  extensive  experience  and  well-earned 
reputation  in  practice  must  have  rendered  him  a  competent  judge  of  their  merits.  We  willingly  commeud 
Prcf.  Taft's  able  and  useful  work  to  the  profession.  —  London  Dental  Jieviete. 


LINDSAY   AND    BLAKISTON's    PUBLICATIONS. 


Tilt's  Change  of  Life 

In  Health  and  Disease.  A  Practical  Treatise  on  the  Nei-vous  and 
other  Affections  incidental  to  Women  at  the  Decline  of  Life.  By 
Edward  John  Tilt,  M.D.     From  the  Third  London  Edition.     In 

one  volume.     Octavo, $3.00 

The  work  is  rich  in  personal  experience  and  observation,  as  well  as  in  ready  and 
sensible  reflection  on  the  experience  and  observation  of  others.  The  book  is  one  that 
no  practitioner  should  be  without,  as  the  best  we  have  on  a  class  of  diseases  that  makes 
a  constant  demand  upon  our  care,  and  requires  very  judicious  management  on  the  part 
of  the  practitioner. — London  Lancet. 

Tuke.     lilustratioiis  of  the  Influence  of  the 
Mind  upon  the  Body.  ByDANiELS.TuKE,M.D.,  ^s^o- 

date  Author  of  "A  Manual  of  Psychological  Medicine,''^  &c.     Octavo. 
Price, $ 

Tyler  Smith's  Obstetrics. 

A  Course  of  Lectures.  By  W.  Tyler  Smith,  M.D.,  Physician,  Ac- 
coucheur, and  Lecturer  on  Midwifery,  &c.  Edited  by  A.  K.  Gard- 
ner, M.D.     With  Illustrations.     Octavo,     ....         $5.00 

Toynbee  on  Diseases  of  the  Ear. 

Their  Nature,  Diagnosis,  and  Treatment.     A  new  London  Edition,  with 

W        a  Supplement.     By  James  Hinton,  Aural  Surgeon  to  Guy^s  Hospi- 

tal,  &c.      With  Illustrations.     Octavo,  ....        $5.00 

Thompson's  Clinical  Lectures  on  Pulmonary 
Consumption,   octavo $2.00 

son's  Cell  Doctrine: 

Its  History  and  Present  State,  with  a  Copious  Bibliography  of  the  Sub- 
ject, for  the  use  of  Students  of  Medicine  and  Dentistry.  By  James 
Tyson,  M.D.,  Lecturer  on  Microscopy  In  the  University  of  Pennsyl- 
vania, &c.,  &c.      With  a   Colored  Plate,  and  numerous  Illustrations 

on  Wood.     Price S2.00 

Dr.  Tyson  furnishes  in  this  work  a  concise  and  instructive  resume  of  the  origin  and 
advance  of  the  doctrine  of  Cell  Evolution.  In  it  we  tind  the  theories  of  Virchow,  liobin, 
Huxley,  Hughes.  Bennett,  Beale,  and  other  distinguished  men.  Its  pagps  contain  wli.it 
could  otherwise  only  be  learned  by  the  perusal  of  many  works,  and  they  supply  tlie 
reader  with  a  continuous,  complete,  and  general  knowledge  of  the  history,  progress, 
•jiV.d  peculiar  phases  of  the  Cell  Doctrine,  accompanied  by  careful  references  and  a 
Bnpious  bibliography. 

Virchow's  Cellular  Pathology. 

Translated  from  the  Second  Edition.     By  Frank  Chance,  B.A.,  M.A., 
&c     With  Notes  and  Emendations,  and  144  Engravings.    8vo.     $5.00 


Ty 

t-  lu 


LINDSAY    AND    BLAKISTON  S    PUBLICATIONS. 


Trousseau's  Clinical  Lectures. 

VOL.  v.,  COMPLETING  THE  WORK,  NEARLY  READY. 

Lectures  on  Clinical  Medicine,  delivered  at  the  Hotel-dieu,  Paris.     By 

A.  Trousseau,  Professor  of  Clinical  Medicine  in  the  Faculty  of  Medv 

cine,  Paris,  &c.,  &c. 

Trousseau's  Lectures  on  Clinical  Medicine,  so  fayorably  received,  as  well  by  the 
profession  of  the  United  States  as  abroad,  are  published  in  this  country  in  conneotioy 
with  the  New  Sydenham  Society,  under  whose  auspices  the  translation  of  Vols.  XL  and 
III.  have  been  made.  Either  of  these  volumes  can  be  furnished  separately,  and  in  order 
to  still  further  extend  the  circulation  of  so  valuable  a  work,  the  Publishers  have  now 
reduced  the  price  to  Five  Dollars  per  volume. 

Contents  of  Volume  I.  —  Translated  and  Edited  by  P.  Victor  Bazire,  M.  D.,  3fc. — 
Lecture  1.  On  Venesection  in  Cerebral  Haemorrhage  and  Apoplexy.  2.  On  Apoplec- 
tiform Cerebral  Congestion,  and  its  Relations  to  Epilepsy  and  Eclampsia.  3.  On 
Epilepsy.  4.  On  Epileptiform  Neuralgia.  5.  On  Glosso-laryngeal  Paralysis.  6.  Pro- 
gressive Locomotor  Ataxy.  7.  On  Aphasia.  8.  Progressive  Muscular  Atrophy.  9. 
Facial  Paralysis,  or  Bell's  Paralysis.  10.  Cross-paralysis,  or  Alternate  Hemiplegia. 
11.  Infantile  Convulsions.  12.  Eclampsia  of  Pregnant  and  Parturient  Women.  13. 
On  Tetany.  14.  On  Chorea.  15.  Senile  Trembling  and  Paralysis  Agitans.  16.  Ce- 
rebral Fever.  17.  On  Neuralgia.  18.  Cerebral  Rheumatism.  19.  Exophthalmic 
Goitre,  or  Graves' Disease.     20.  Angina  Pectoris.     21.  Asthma.     22.  Hjoping  Cough. 

23.  On  Hydrophobia. 

Contents  of  Volume  II. — Translated  from  the  Edition  of  1868  [being  the  last  revised 
and  enlarged  edition),  by  John  Rose  Cormack,  M.  D.,  Edin.,  F.R.S.E  ,^Sfc.  — Lecture  1. 
Small-pox.  2.  Variolous  Inoculation.  3.  Cow-pox.  4.  Chicken-pox.  5.  Scarlatina. 
B.  Measles,  and  in  particular  its  unfavorable  Symptoms  and  Complications.  7.  Rubeola. 
8.  Erythema  Nodosum.  9.  Erythema  Papulatum.  10.  Erysipelas,  and  in  particular 
Erysipelas  of  the  Face.  11.  Mumps.  12.  Urticaria.  13.  Zona,  or  Herpes  Zoster. 
14.  Sudoral  Exanthemata.  15.  Dothinenteria,  or  Typhoid  Fever.  16.  Typhus.  17. 
Membranous  Sore  Throat,  and  in  particular  Herpes  of  the  Pharynx.  18.  Gangrenous 
Sore  Throat.     19.  Inflammatory  Sore  Throat.     20.  Diphtheria.     21.   Thrush. 

Contents  of  Volume  III. — Translated  from  the  Edition  of  1868,  by  John  Rose  Cormack, 
M.D.,  Edin.,  F.R.S.E.,  Si'C. — Lecture  22.   Specific  Element  in  Disease.     23.  Contagion. 

24.  Ozasna.  25.  Stridulous  Laryngitis,  or  False  Croup.  26.  Oedema  of  the  Larynx. 
27.  Aphonia:  Cauterization  of  the  Larynx.  28.  Dilatation  of  the  Bronchi  and  Bron- 
chorrhoea.  29.  Hemoptysis.  30.  Pulmonary  Phthisis.  31.  Gangrene  of  the  Lung. 
32.  Pleurisy:  Paracentesis  of  the  Chest.  33.  Traumatic  Efi'usion  of  Blood  into  the 
Pleura:  Paracentesis  of  the  Chest.  34.  Hydatids  of  the  Lung.  35.  Pulmonary 
Abscesses  and  Peripneumonic  Vomicoe.  36.  Treatment  of  Pneumonia.  37.  Paracen- 
tesis of  the  Pericardium.  38.  Organic  AflFections  of  the  Heart.  52.  Alcoholism.  62. 
Spermatorrhoea.  63.  Nocturnal  Incontinence  of  Urine.  64.  Glucosuria:  Saccharine 
Diabetes.     65.  Polydipsia.     67.  Vertigo  a  Stomacho  Lteso. 

4  Volumes  Octavo.  Vols.  1,  2,  and  3,  Price  $5.00  each  ;  Vol.  4,  Price  $4.00 
OPINIONS  OF  THE  PRESS. 

"Trousseau  furnishes  us  with  an  example  of  the  best  kind  of  Clinical  teaching.  It  is 
a  book  that  deserves  to  be  popularized.  The  translation  is  perfect."  —  Medical  Tima 
and  Gazette. 

"The  great  reputation  of  Prof.  Trousseau  as  a  practitioner  and  teacher  of  Medicine 
in  all  its  branches,  renders  the  present  appearance  of  his  Clinical  Lectures  particularly 
welcome."  —  Medical  Press  and  Circular. 

"The  publication  of  Trousseau's  Lectures  will  furnish  us  with  one  cf  the  very  best 
practical  treatises  on  disease  as  seen  at  the  bedside."  —  British  and  Foreign  Medieo- 
Chirurgical  Review. 

"A  clever  translation  of  Prof.  Trousseau's  admirable  and  exhaustive  work,  the  best 
bock  of  reference  upon  the  Practice  of  Medicine." — Indiaii  Medical  Gazette. 

'The  Lectures  of  Trousseau,  in  attractiveness  of  manner  and  richness  of  thoroughly 
practical  matter,  worthily  takes  a  place  beside  the  classical  lectures  of  Wat.ion  and 
firiive'j."  —  British  Medical  Journal. 

•  I'roussoau  is  essentially  the  French  Graves,  and  his  lectures  should  sooEer  that 
ihis  Uisve  been  nanalaied  into  English."  —  Lancet. 


LINDSAY    AND    BLAKISTON'S    PlTBLICATloyS. 


Wythes'  Physician's  Pocket,  Dose,  and  Symp- 
tom Book.      THE  TENTH  EDITION. 

Containing  the  Doses  and  Uses  of  all  the  PHncipal  Articles  of  the  Materia 
Medica,  and  Original  Preparations ;  A  Table  of  Weights  and  Mea- 
sures,  Rules  to  Proportion  the  Doses  of  Medicines,  Common  Ahbre 
motions  used  in  Writing  Prescriptions,  Table  of  Poisons  and  Antidotes, 
Classification  of  the  Materia  Medica,  Dietetic  Preparations,  Table  of 
Symptomatology,  Outlines  of  General  Pathology  and  Therapeutics,  &c. 
ByJosEPHH.  Wythes,  A.M.,  M-D-,&c.    The   Tenth  Revised  Edition. 

Price,  in  cloth, 81.25 

"       leather,  tucks,  with  pockets,  .         .         .  1.50 

This  little  manual  has  been  received  with  much  favor,  and  a  large  number  of  copiea 
gold.  It  was  compiled  for  the  assistance  of  students,  and  to  furnish  a  vade  mecum  for 
the  general  practitioner,  which  would  save  the  trouble  of  reference  to  larger  and  more 
elaborate  works.  The  present  edition  has  undergone  a  careful  revision.  The  thera- 
peutical arrangement  of  the  Materia  Jlcdica  has  been  added  to  it,  together  with  such 
other  improvements  as  it  was  thought  might  prove  of  value  to  the  woi-«. 

Williams  on  Consumption,  london  edition. 

Pulmonary  Consumption;  Its  Nature,  Varieties,  and  Treatment.  With 
an  Analysis  of  One  Thousand  Cases  to  exemplify  its  duration.  By 
C.  J.  B.  Williams,  M.D.,  F.R.S.,  author  of  Williams'  Principles 
of  Medicine,  Senior  Consulting  Physician  to  the  Hospital  for  Con- 
sumption, &c.  &c.,  and  Charles  Theodore  Williams,  M.D.,  Physi- 
cian to  the  Hospital  for  Consumption.  Brompton.  Demy  Octavo. 
Price, $3.00 

This  edition  of  Williams  on  Consumption  is  issued  in  the  United  States  by  special 
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Diseases,  and  if  he  has  had  to  modify  much  of  his  teaching,  and  more  of  his  treatment, 
he  can  still  speak  from  a  more  enormous  experience,  and  a  closer  study  of  the  morbid 
processes  involved  in  tuberculosis,  than  most  living  men,  and  he  can  look  backwards 
and  forwards  with  as  much  satisfaction  as  most  of  his  contemporaries."  —  London 
Lancet. 

Walker  on  Intermarriage. 

Or,  the  Mode  in  which,  and  the  Causes  why,  Beauty,  Health,  and  Intellect 
result  from  certain  Unions,  and  Deformity,  Disease,  and  Insanity  from 
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Waring  s  Practical  Therapeutics,    a  new  edition. 

Considered  chiefly  with  reference  to  Articles  of  the  Materia  Medica. 
By  Edward  John  Waring,  F.R.C.S.,  F.L.S.,  &c.,&c.  Second  American, 
from  the  Third  London  Edition.     Royal  Octavo. 

Price  in  Cloth,  85. oo;  Leather,  6.00. 

There  are  many  features  in  Dr  Waring's  Therapeutics  which  render  it  especially 
vjihuible  to  the  Practitioner  and  Student  of  Medicine,  much  important  and  reliable 
information  being  found  in  it  not  contained  in  similar  works;  it  also  differs  from 
them  in  its  completeness,  the  convenience  of  its  arrangement,  and  the  greater  promi- 
nence given  to  the  medicinal  application  of  the  various  articles  of  the  Materia  Modica 
in  the  treatment  of  morbid  conditions  of  the  Human  Body,  &c.  It  is  divided  into 
two  parts,  the  alphahetical  arrangement  being  adojjted  throughout;  there  is  also  added 
an  excellent  Index  of  Diskases,  with  a  list  of  the  medicines  applicable  as  remedies, 
and  a  full  Ixdex  of  the  medicines  and  preparations  noticed  in  the  work. 

"  This  new  edition  of  Waring's  Practical  Therapeutics  has  been  altered  and  improved  with  great 
judgment.  A  satisfactory  account  of  new  agents — chloral,  apomorphia,  nitrous  oxide,  carbolic  acid, 
&c.,  is  introduced  without  adding  to  its  bulli.  The  additions  are  made  with  remarkable  skill  in  con- 
densation.   It  is  one  of  the  best  manuals  of  therapeutics  yet  in  existence." — Brit.  Med.  Journal. 

"There  has  been  no  scarcity,  latterly,  of  works  of  this  class,  several  of  them  we  regard  as  having 

great  professional  value  ;  but,  it  must  bo  allowed,  we  think,  that  this  holds  no  inferior  place  among 
them.  Stillj's  is  a  national  book,  but  much  more  voluminous :  and,  therefore,  while  it  is  high  author- 
ity. It  is  less  convenient  for  office  use.  Furthermore,  we  prefer  the  literary  arrangement  and  execu- 
tion of  Wariyig.  It  can  be  used  with  more  readiness  and  always  relied  on  for  the  correctness  of  ita 
facts.  In  the  daily  treatment  of  diseases,  it  seems  to  supply  everything  that  can  be  desired.  The 
articles  are  arranged  alphabetically,  and  a  paragraph  is  devoted  to  their  physical  description  and 
scientific  character.  Their  therapeutic  uses,  however,  constitute  the  bulk  of  the  volume ;  and  in  this 
respect  the  labor  has  been  very  thorough." — Druggists''  Circular. 

"The  plan  of  this  work  is  admirable,  and  well  calculated  to  meet  the  wants  of  the  busy  practi- 
tioner. There  is  a  remarkable  amount  of  information,  accompanied  with  judicious  comments,  im- 
parted in  a  concise  yet  agreeable  style.  The  indications  for  the  application  of  remedies  are 
sufficiently  comprehensive,  and  their  mode  of  action  generally  accounted  for  on  rational  grounds. 
The  publishers  have  well  performed  their  part,  and  we  trust  that  their  enterprise  in  introducing  the 
work  to  the  profession  in  America  may  meet  with  that  encouragement  which  the  inherent  merits  of 
the  treatise  itself  are  entitlea  to  command." — Medical  Record. 

"  Our  admiration,  not  only  for  the  immense  industry  of  the  author,  but  also  of  the  great  practical 
value  of  the  volume,  increases  with  every  reading  or  consultation  of  it.  We  wish  a  copy  could  be 
put  in  the  hands  of  every  student  or  practitioner  in  the  country.  In  our  estimation  it  is  the  best 
book  of  the  kind  ever  written." — A'.  Y.  Medical  Journal. 

Ward  on  Some  Affections  of  the  Liver 

And  Intestinal  Canal,  with  Remarks  on  Ague  and  its  Sequelce,  Scui^vy, 
Purpura,  Sc.  By  Stephen  H.  Ward,  M.D.,  F.R.C.P.,  Physician 
to  the  Seamanh  Hospital,  &c.,  &c.     Octavo.     Price,  .         .  S3. 00 

Wedl's  Dental  Pathology.  The  Pathology  of  the  Teeth. 
With  Special  Reference  to  their  Anatomy  and  Physiology.  By  Prof. 
Wedl,  of  the  ilniversity  of  Vienna.  Fir.st  American  Edition,  Trans- 
lated by  W.  E.  BoARDMAN,  M.D.,  with  Notes  by  Thos.  B.  Hitchcock, 
M.D.,  Professor  of  Dental  Pathology  and  Therapeutics  in  the  Dental 
School  of  Harvard   University,  Cambridge.      With  105  Illustrations. 

Price,  in  Cloth, -  .         •         $f  5<^ 

"       "  Leather, ^-^0 


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Walton's  Operative  Ophthalmic  Surgery. 

By  Haynes  Walton,  F.R.C.S.,  Surgeon  to  the  Central  London  Ophtkal- 
mic  Hospital,  &c.  With  169  Illustratiom.  Edited  by  S.  LiTrEi.i,, 
M.D.,  Surgeon  to  the  Wills  Hospital  for  the  D'tseases  oj  the  Eye,  &c. 
Octavo $4.00 

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Watson's  Practice  abridged. 

A  Synopsis  of  the  Lectures  on  the  Principles  and  Practice  of  Physic.  De- 
livered at  King's  College,  London,  by  Thomas  Watson,  M.D.,  Fellow 
of  the  Royal  College  of  Physicians,  &c.,  &c.  From  the  last  London 
Edition.  With  a  concise  but  Complete  Account  of  the  Properties,  Uses, 
Preparations,  Doses,  &c.,  of  all  the  Medicines  mentioned  in  these  Lectures, 
and  other  Valuable  Additions,  by  J.  J.  Meylor,  A.M.,  M.D.,  &c.,  &c. 
A  neat  Locket  Volume  bound  in  cloth  flexible.         .        .        .        $2.00 

Wells'  Treatise  on  the  Diseases  of  the  Eye, 

illustrated   by  Ophthalmoscopic  Plates  and  Numerous  Engravings  on 
Wuod.     By  J.  ScELBERU  vVklls,  Ophthalmic  Surgeon  to  King^s  College 
Hospital,  Sc.     Second  London  Edition,  cloth,  $6.50;  leather,  $7  50. 
This  is  the  author's  own  edition,  printed  in  London  under  his  supervision,  and  issued 
in  this  country  by  special  arrangement  with  him. 

Wright  on  Headaches. 

Their  Causes  and  their  Cure.  By  Henry  G.  Wright,  M.D.,  Membet 
of  the  Royal  College  of  Physicians,  &C.  &e.  From  the  Fourth  London 
Edition.     12mo.     Cloth S1.25 

"  Few  afiFections  are  more  unmanageable  and  more  troublesome  than  those  of  which 
this  essay  treats;  and  we  doubt  not  that  any  suggestions  by  which  we  can  relie-ve 
them  will  be  gladly  received  by  physicians.  The  author's  plan  is  simple  and  practical. 
He  treats  of  headaches  in  childhood  and  youth,  in  adult  life  and  old  age,  giving  in 
each  their  varieties  and  symptoms,  and  their  causes  and  treatment.  It  is  a  most  satis- 
factory monograph,  as  the  mere  fact  that  this  is  a  reprint  of  the  fourth  edition,  testifiesj. 

"  The  great  pains  which  the  author  takes  to  clear  up  the  diiFerential  diagnosis  of  the 
different  varieties,  and  establish  a  satisfactory  basis  for  rational  treatment,  are  every- 
where visible.  While  such  a  valuable  fund  of  information  is  offered  to  the  practitioner 
»t  the  cost  of  a  single  visit,  he  should  not  let  his  patient  suffer  for  want  of  it."  -  • 
Medical  and  Surgical  Reporter. 

Wells  on  Long,  Short,  and  Weak  Sight,  and 

their  Treatment  by  the  ^-nentijic  Use  of  Spectacles.  Third  Edition  Re- 
vised, with  Additions  and  Numerous  niustr3,tions.  By  J.  SosLBr.an 
Wells.     Octavo.         .....  P"c«.  $>-^'  00 


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Carpenter's  Microscope  and  its  Revelations.  The  Fourth  Edition,  .  5.00 
Brodhurston  the  Deformities  of  the  Human  Body.  Numerous  Illustrations,  4.25 
Acton  on  Prostitution.  The  Second  Edition,  enlarged.  8vo,  .  .  .  5.00 
Heath  s  Manual  of  Minor  Surgery  and  Bandaging.  Fourth  Edition,  .  2.25 
Jones'  Defects  of  Sight  and  Hearing.  Second  Edition,  with  Engravings,  1.25 
Wilson's  Management  of  the  Skin  and  Hair.  Seventh  Edition,  .  .  1.25 
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Thomson's  Diseases  of  the  Prostate.     Tiiird  Edition.    Bvo,          .         .         .     4. -50 
Thompson's  Practical  Lithotomy  and  Lithotrity.     Second  Edition,         .     4.50 
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Sankey's  Lectures  on  Mental  Diseases.  Octavo,  .....  3.25 
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Taylor  on  Poisons  in  Relation  to  Medical  Jurisprudence.    2d  Edition..     5.00 
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Guy's  Hospital  Reports.     Third  Series.    Vol.  17  for  1872,     ....     3.50 

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NEW  SYDENHAM  SOCIETY'S  PUBLICATIONS. 

VOLUMKS  TO   BE   ISSUED   IN   1872. 

I.  STRICKER'S  MANUAL  OF  HISTOLOGY.    Tiansluted  by  Mr.  Power. 

Vol.  II. 

TROUSSEAU'S  LECTURES  ON  CLINICAL  MEDICINE.    Fifth  and 


II. 

in. 

IV. 


Vol. 


?0L. 


1859.     (First  Tear.) 

1.  DiDAT  on  Infantile  Syphilis. 

2.  GOOCH  on  Diseases  of  Women. 

3.  Memoirs  on  Diphtheria. 

4.  Van  der  Kolk  on  the  Spinal  Cord,  &c. 

6.  MOKOQRAPHS   (Kussnial   &   Tenner,   Grjefe, 
Wagner,  &c.) 

1860.    {Second  Tear.) 

6.  Dr.  Bright  on  Abdominal  Tumors. 

7.  Frerichs  on  Diseases  of  the  Liver.     Vol.  I. 

8.  A  Yearbook  fur  1859. 

9.  Atlas  of  Portraits  cf  Skin  Diseases.     (1st 

Fasciculus.) 


concluding  Volume,  with  Index. 

RINDFLEISCH'S  MANUAL  OF  PATHOLOGICAL  HISTOLOGY. 

A  TWELFTH  FASCICULUS  OF  THE  ATLAS  OF  LIFE-SIZE  POR- 
TRAITS OF  SKIN-DISEASES. 

LINDSAY  ci;  BLAKISTOX,  rhiladelphia, 

AGENTS  IN  THE  UNITED  STATES. 

WORKS   ALREADY  PUBLISHED. 

1865.  (Seventh  Tear.) 
Vol.  25.  A  Yearbook  for  18&4. 

26.  Casper's  Forensic  Medicine.    Vol.  IV. 

27.  Atlas  of  Portraits  of  Skin  Diseases.  (5th 
Fasciculus.) 

1866.  (Eighth  Tear.) 
Vol.  28.  BerxctzAGoupil  on  the  Diseases  of  Women 

29.  Atlas  of  Portraits  of  Skin  Diseases.  (6th 
Fasciculus.) 

30.  Hebra  on  Diseases  of  the  Skin.     Vol.  I. 

31.  Bernutz  &  GouPiL  on  Diseases  of  Women. 
Vol.  II. 

1867.  (Ninth  Tear.) 
Vol.  32.  A  Bienni.al  Retrospect  of  Medicine  and  Sur- 
gery. 

33.  Griesinoer  on  Mental  Pathology  and  Thera- 
peutics. 

34.  Atlas  of  Portraits  of  Skin  Diseases.  (7th 
Fasciculus.) 

35.  TEonssEAu's  Clinical  Medicine.    Vol.  I. 

1868.  (Te7ith  Tear.) 
Vol.  36.  The  Collected  Works  of  Dr.  Addison. 

37.  IIebra  on  SkinD  iseases.     Vol.  II. 

38.  Lancereaux's  Treatise  on  Syphilis.     Vol.  I. 

39.  Atlas  of  Portraits  of  Skin  Diseases;  (8th 
Fasciculus.) 

40.  A  Catalogue  of  the  Portraits  issued  in  the 
Society's  Atlas  of  Skin  Diseases.  (Part  I.) 

1869.     (Eleventh  Tear.) 
Vol.  41.  Trousseau's  Clinical  Medicine.    Translated 
and  edited  by  Dr.  Rose  Cormack.  Vol.  XL 

42.  Biennial  Retrospect  of  Medicine  and  Sur- 
gery, for  1867 -S.  Edited  by  Dr.  Anstie 
Dr.  Barnes,  Mr.  Holmes,  Mr.  Power,  Mr 
Carter,  and  Dr.  Underwood. 

43.  L.ancereaux  on  Syphilis.  Translated  by  Dr 
Whitley.     Vol.  II.,  cnnipUting  the  Work 

44.  A  Ninth  Fasciculus  of  the  Atlas  of  Por 
traits  of  Skin  Diseases 

1871.     (Thirteenth  Year.) 
Wunderlicli  on  Temperature  in  Disease, 
Trousseau's  Clinical  Medicine.     Vol.  IV. 
A  Biennial  Retrospect  of  Medicine  and  Sur- 
gery for  1869-70. 
Fasciculus  of  Skin  Diseases. 


1861.    (Tliird  Tear.) 
▼oi.  10.  A  Yearbook  for  1860. 

11.  Monographs  (C/.erTuak,  Dusch,  Radicke,  &c.) 

12.  Casper's  Forensic  Medicine.    Vol.  I. 

14.  Atlas  of  Portraits  of  Skin  Diseases.    (2nd 

Fasciculus.) 

1862.    (F<mrth  Tear.) 
Vol.  13.  Frerichs  on  Diseases  of  the  Liver.    Vol.  II. 

15.  A  Yearbook  for  1861. 

16.  Casper's  Forensic  Medicine.    Vol.  11. 

17.  Atlas  of  Portraits  of  Skin  Diseases.     (3d 

Fasciculus.) 

1863.  (Fifth  Tear.) 
Vou  18.  Kramer  on  Diseases  of  the  Ear. 

19.  A  Yearbook  for  1862. 

20.  Neubauer  and  Vogel  on  the  Urine. 

1864.  (Sixth  Tear.) 
Vol.  21.  Casper's  Forensic  Medicine.     Vol.  III. 

22.  DoNDERS  on  the  Acconiniodation  and  Refrac- 

tion of  the  Eve. 

23.  A  Yearbook  for  1863. 

24.  Atlas  of  Portraits  of  Skin  Diseiises.    (4th 

Fasciculus.) 

1870.     {Twelfth  Year.) 
Trousseau's  Clinical  Medicine.     Vol.  III. 
Strieker's  Manual  of  Histology.     Vol.  I. 
Niemeyer's  Lectures  on  Phthisis. 
A  Tenth  Fasciculus  of  the  Atlas  of  Skin  Dis- 
eases. 


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Boston  City  Hospital  Medical  and  Surgical  Reports,     . 

Manchester  Medical  and  Surgical  Reports,    . 

The  Physician's  Visiting  List  for  1872,  prices  reduced. 

Clinical  Society's  Transactions,    ......     London, 

St.  Andrew's  Medical  Graduates'  Association  Reports, 

St.  Thomas'  Hospital  Reports,     ......     London, 

The  Liverpool      "  "......" 

St.  George's         "  «« " 

St.  Bartholomew "  " " 

Guy's  "  "  .         .  ..." 

Obstetrical  Society's  Transactions ♦« 

Pathological     "  "  ....." 

Medico- Chirurgical  Society's  Transactions,  ....  " 

The  New  Sydenham  Society's  Publications.     3  to  4  volumes 

annually,  .........  " 

Beale's  Archives  of  Medicine.  Colored  plates.  Part  17  just  out. 

The  Ophthalmic  Hospital  Reports,        .....     London, 

HALF-  YEAML  Y. 

Braithwaite's  Retrospect  of  Medicine  and  Surgery,        .         .     Reprint, 
Ranking' s  Half- Yearly  Abstract  "  "  .         .  "         . 

Half-  Yearly  Compendium  of  Medical  Science,       ..... 
Journal  of  Anatomy  and  Physiology,  .....     London,  . 


PRICE 

Per 
Annam. 

$4  00 

4  00 

5  00 


QUARTERLY. 

American  Journal  of  the  Medical  Sciences,    . 
British  and  Foreign  Medico- Chirurgical  Review,   . 
The  Dublin  Quarterly  Journal  of  Medicine, 
American  Journal  of  Syphilography  and  Dermatology, 
Microscopical  Journal,         ...... 

The  American  Journal  of  Obstetrics,    .... 

Joxirnal  of  Psychological  Medicine,       .... 

Journal  of  New  Remedies,  Therapeutics,  Pharmacy,  ^c. 

MONTHLY. 

The  American  Journal  of  Pharmacy,  .... 

Journal  of  the  Gynecological  Society, 

The  London  Lancet,    ....... 

The  Medical  and  Surgical  Journal,       .... 

The  Practitioner.     Edited  by  F.  E.  Anstie,  M.D. 
The  American  Chemist,        ...... 

New  York  Medical  Journal,        ..... 


Philadelphia, 
London,  . 
Dublin,  . 
New  York, 
London, . 
New  York, 


Philadelphia, 
Boston,    . 
Reprint, 
Edinburgh, 
London,  . 
New  York, 
New  York, 


SEMI-MONTHL  Y. 

The  Medical  Times, Philadelphia, 

The  Medical  Record, New  York, 

WEEKLY. 

The  London  Lancet, London,  . 

"    Medical  Times  and  Gazette,  .....  "         . 

"    British  Medical  Journal,       ......  "         • 

"    Pharmaceutical  Journal,       ......  '*         • 

"    Medical  and  Surgical  Reporter, Philadelphia, 

*'    Medical  and  Surgical  Journal,       .....  Boston,    . 

A.ny  other  Journals  will  be  furnished  to  order. 


10  00 

1 

50 

2 

50 

2 

50 

3 

00 

5 

00 

10 

00 

10 

00 

3 

00 

8 

00 

4  00 

5 

00 

2 

00 

3 

00 

5 

00 

5 

00 

8 

00 

4 

00 

5 

00 

4 

00 

4 

00 

4 

00 

12 

00 

12 

00 

12 

0(^ 

6 

00 

5 

00 

4  00 


i 


Lindsay  &  Blakiston's 
PHYSICIAN'S  VISITING  LIST. 

mw  EEADY  rOE  1873. 

"The  simplest  of  all  the  visiting  lists  published,  it  must  continue  to  hold,  whai  5* 
now  has,  the  preference  over  all  other  forms  of  this  indispensable  companion  for  the 
Physician." — A"ew  Fork  Med.  Journal. 

OOnSTTEISTTS. 


1.  Table  of  Signs,  or  Guide  for  Registeriug  Visits,  En- 

gagements, &c. 

2.  An  Almanac 

3.  Marsliall  Hall's  Ready  Method  in  Asphyxia. 

4.  Poisons  and  their  Antidotes. 

5.  Talilo  for  Calculating  the  Period  of  Utero-Ocstation. 

6.  The  Visiting  List  arranged  for  25,  50,  75,  or  100 

Patients. 


7.  Memoranda  pages  for  every  month  in  the  year. 

8.  Pages  for  Addresses  of  Patients,  Ac. 

9.  "        Bills  and   Accounts  asked   for  and    de- 

livered. 

10.  "        Obstetric  Engagements. 

11.  "        Vaccination. 

12.  "        Recording  Obstetric  Cases,  Deaths,  and 

for  General  Memoranda. 


For  26  Patients 

weekly 

50 

it 

<i 

75 

" 

<i 

100 

it 

(< 

50 

<( 

«'2vo 

100 

(( 

"2vo 

SIZES  AND    PRICE. 

Tucks,  pockets,  and  pencil, 


$1 

00 

1 

25 

1 

50 

2 

00 

2 

50 

3 

00 

/Jan.  to  June.  "1  ,, 

t  July  to  Dec.    j  

"^'»>'{J".'tUr}    "  •  ■  •  •  • 

Also,  AN  INTERLEAVED  EDITION, 

for  the  use  of  Country  Physicians  and  others  who  compound  their  own  Prescriptions, 
or  furnish  Medicines  to  their  patients.  The  additional  pages  can  also  be  used  for  Special 
Memoranda,  recording  important  cases,  &c.,  &c. 

For  25  Patients  weekly,  interleaved,   tucks,  pockets    etc.,         .         .         .         .    $1  60 
50       "  "  "  u         .<        '     ..  ....       1  75 

»»      '•  ••    ^'«'»{J"y'.°.ir}"         "         .       .       .       .    soo 

This  Visiting  List  has  now  been  published  for  Twenty  Years,  and  has 
met  with  such  uniform  and  hearty  approval  from  the  Profession,  that  the 
demand  for  it  has  steadily  increased  from  year  to  year. 

The  Publishers,  in  order  to  still  further  extend  its  circulation  and  useful- 
ness, and  to  keep  up  the  reputation  which  it  has  so  long  retained,  of  being 

THE  CHEAPEST  AND  BEST, 

as  well  as  the  Oldest  Visiting  List  published,  have  now  made  a  very 
considerable  r'educlion  in  the  price. 

It  can  be  procured  from  the  principal  booksellers  in  any  of  the  large 
cities  of  the  United  Stales  and  Canada,  or  copies  will  be  forwarded  by  mail, 
free  of  postage,  by  the  Publishers,  upon  receipt  by  them  of  the  retail  price 
as  annexed. 

In  ordering  the  work  from  other  booksellers,  order 

Liiidsatj  &  lUdkiston^s  Phi/siclan's  Visiting  List. 
And  la   all  cases,  whether  ordering  from  the  Publishers  or  otherwise, 
specify  the  size,  style,  &c.,  wanted. 

It  is,  beyond  all  doubt,  the  most  complete  and  yet  the  simplest  Visiting  List  which 
is  published.  In  our  opinion,  it  is  inv.iluable  to  the  practitioner  in  busy  practice,  and, 
besides  saving  him  a  great  deal  of  trouble,  will  prevent  his  losing  a  considerable  sum 
of  money  during  the  year,  by  neglecting,  through  forgetfulness,  to  enter  visits  made. 
Those  who  have  made  use  of  this  Visiting  List  would  not  be  without  it  for  thrice  its 
price.  We  therefore  know  we  are  doing  our  readers  a  good  turn  when  we  strongly 
recommend  it  to  their  attention.  —  Canada  Medical  Journal,  December,  1871. 


Medical  Text-Books, 

PUBLISHED  BY 

LINDSAY  &  BLAKISTON,  Philadelphia. 


AITKEX'S  Science  an«l  Practice  of  Medicine.    The  Third  American  Edition,  with  Addition* 

by  the  American  Editor,  reprinted  from  tlie  Sixtli  London  Edition;    Revised,  remodelled,  and  much 

of  it  rewritten  by  the  Autlior,  and  with  many  New  Illustrations.     2  Volumes,  Royal  Octavo. 
SAXOKRSOX  &.  FOSTER'S  Handbook  for  tlie  I..aboratory.    Being  Practical  Exercise* 

for  Students  in  Physiology  and  Histology.     Preparing. 
C.4ZE.\UX"S  Text-BooK  of  Obstetrics.  — Fifth  American  Edition.    Illustrated. 
WAUIXCJ'S  Practical  Tlierapentics.  — From  the  Third  London  Edition. 
KIXi>FE3:i.«»t'BI"S  Text-Book  of  PatholO|i^ical  Histolog^y. —  Containing  208  Elaborately 

Kxic-iited  Microscopical  Ilhistintious. 
TAXNER'S  Practice  of  Medicine.— Fifth  American  from  the  Sixth  London  Edition. 
MEIGS  «S:  PEPPER'S  Practical  Treatise  on  the  Diseases  of  Children.— Fourth  Ed. 
TANNER  «lt  MEADOWS  Diseases  of  Infancy  and  Childhood.— Third  American  Ed. 
BIDDI^E'S  Materia  Medica,  for  Students.     Fourth  Edition.    With  Illustrations. 
4»ANT'S  Science  and  Practice  of  Surgery.— 470  illustrations. 

HARRIS'S  Principles  and  Practice  of  Dentistry The  Tenth  Revised  Edition 

PAGET'S  Surgical  Pathology.— Bi/  Turner.    Third  London  Edition 

SOE1.BERG  WEliliS  on  Diseases  of  the  Eye.— Second  London  Edition. 

BYFOBD'S  Practice  of  Medicine  and  Snrgery,  applied  to  the   Diseases  of 

Women.- Second  Edition.    Illustrated. 
HEWITT'S  Diagnosis  and  Treatment  of  the  Diseases  of  Women.-Third  Edition. 

-  HEADLAND  on  the  Action  of  Medicines.— Sixth  American  Edition. 
BE.\EE*S  How  to  Work  with  the  Microscope. —  Fourth  Edition. 
HARIiElT  on  the  Urine  and  its  Derangeniont««.    'With  Illustrations. 

MANUALS   FOR   STUDENTS. 

ME.\DOW'S  Mannal  of  Midwifery.— Second  Edition  Illustrated. 

ATTHIIili'S  Manual  of  the  Diseases  of  Women.— With  Illustrations. 

EAWSON'S  Diseases  and  Injuries  of  the  Eye,  their  Medical  and  Surgical  Treatment. 

CHEW'S  Eectures  on  Medical  Education. 

MENDENHAIilj'S  Medical  Student's  Vadc  Mecum.— The  Tenth  Edition.    224 ninstratione, 

ROBERTSON'S  Manual  for  Extracting  Teeth.— Second  Edition.    Kevlsed. 

DIXON'S  Practical  Study  of  the  Diseases  of  the  Eye.— Third  Edition. 

PEREIRA'S  Physician's  Prescription  Book.— The  Fifteenth  Eevised  Edition. 

REESE'S  Analysis  of  Physiology.— Second  Edition. 

WYTHES'  Pocket  Dose  and  Symptom  Book.— Tenth  Edition,  with  Additions. 

BARTH  &  ROGER'S  Mannal  of  Auscultation  and  Percussion.— Sixth  Edition. 

CXEAVEEAND'.S  Pronouncing  Medical   LiCxlcon.— Thirteenth  Edition. 

L.EGG'S  Guide  to  the  Examination  of  the  Urine.— Third  London  Edition. 

HIEli's    Pocket   Anatomist,  for  the  use  of  Students. 

TANNER'S  Meiiioran«la  of  Poisons.  —  From  the  Third  London  Edition. 

RIGBY'S  Obstetric  Meuiornnda.     Fourth  Edition. 

yf  complete  'Descriptive  Catalogue  of  their  Publications .^  together 
with  a  classified  and  priced  list  of  all  recent  Medical  Books .^  American 
and  Englishy  furnished  or  mailed  free  on  application,  ^a  V" 


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